Provider Demographics
NPI:1669000246
Name:WHITMORE, JASON LEROY
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEROY
Last Name:WHITMORE
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 1:437 QUARTER HORSE DR
Mailing Address - Street 2:
Mailing Address - City:BEAR RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9592
Mailing Address - Country:US
Mailing Address - Phone:307-679-8274
Mailing Address - Fax:
Practice Address - Street 1:437 QUARTER HORSE DR
Practice Address - Street 2:
Practice Address - City:BEAR RIVER
Practice Address - State:WY
Practice Address - Zip Code:82930-9592
Practice Address - Country:US
Practice Address - Phone:307-679-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health