Provider Demographics
NPI:1629263819
Name:WELLS, JASON CHARLES (HM1 IDC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:CHARLES
Last Name:WELLS
Suffix:
Gender:M
Credentials:HM1 IDC
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:CHARLES
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HM1 IDC
Mailing Address - Street 1:PSC BOX 20116
Mailing Address - Street 2:MSOSG, MARSOC
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0116
Mailing Address - Country:US
Mailing Address - Phone:910-450-6109
Mailing Address - Fax:
Practice Address - Street 1:PSC BOX 20116
Practice Address - Street 2:MSOSG, MARSOC
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0116
Practice Address - Country:US
Practice Address - Phone:910-450-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman