Provider Demographics
NPI:1659820199
Name:JASON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1208
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:6692 MIDDLE RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-9602
Practice Address - Country:US
Practice Address - Phone:315-483-1199
Practice Address - Fax:315-483-2451
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283665164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY283665OtherLICENSE