Provider Demographics
NPI:1689946071
Name:WHITE, JASON LANTZ (IDMT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LANTZ
Last Name:WHITE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5124
Mailing Address - Country:US
Mailing Address - Phone:229-560-1598
Mailing Address - Fax:
Practice Address - Street 1:3280 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY A F B
Practice Address - State:GA
Practice Address - Zip Code:31699-1500
Practice Address - Country:US
Practice Address - Phone:229-257-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians