Provider Demographics
NPI:1558056481
Name:PETTUS, JASON PAUL
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:PETTUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WHISPERING OAK DR
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-2065
Mailing Address - Country:US
Mailing Address - Phone:501-400-5306
Mailing Address - Fax:
Practice Address - Street 1:16 WHISPERING OAK DR
Practice Address - Street 2:
Practice Address - City:MABELVALE
Practice Address - State:AR
Practice Address - Zip Code:72103-2065
Practice Address - Country:US
Practice Address - Phone:501-400-5306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR332U00000X
AR942803758172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No332U00000XSuppliersHome Delivered Meals