Provider Demographics
NPI:1659974467
Name:MANTEL, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MANTEL
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 1:2106 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-2218
Mailing Address - Country:US
Mailing Address - Phone:219-378-9042
Mailing Address - Fax:
Practice Address - Street 1:2106 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2218
Practice Address - Country:US
Practice Address - Phone:219-378-9042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024514A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist