Provider Demographics
NPI:1629266036
Name:MEYER, JASON JOHN (AUD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JOHN
Last Name:MEYER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CORPORATE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:920-887-9655
Practice Address - Street 1:384 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5546
Practice Address - Country:US
Practice Address - Phone:920-233-3307
Practice Address - Fax:920-887-9655
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI375-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41144300Medicaid