Provider Demographics
NPI:1629542923
Name:WALSH, JASON P
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:WALSH
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 1:3100 TELEGRAPH AVE STE 2102
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3210
Mailing Address - Country:US
Mailing Address - Phone:510-286-8160
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE STE 2102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3210
Practice Address - Country:US
Practice Address - Phone:510-286-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009795363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily