Provider Demographics
NPI:1679754261
Name:BLAIR, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BLAIR
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 1:3121 W BAJADA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-5822
Mailing Address - Country:US
Mailing Address - Phone:623-505-6388
Mailing Address - Fax:
Practice Address - Street 1:20402 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3636
Practice Address - Country:US
Practice Address - Phone:623-445-4952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-24
Last Update Date:2007-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist