Provider Demographics
NPI:1679914469
Name:SHUPE, JASON (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SHUPE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:554 E FOOTHILL BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1222
Mailing Address - Country:US
Mailing Address - Phone:909-248-3437
Mailing Address - Fax:844-380-6565
Practice Address - Street 1:554 E FOOTHILL BLVD STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1222
Practice Address - Country:US
Practice Address - Phone:909-248-3437
Practice Address - Fax:844-380-6565
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A13620207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine