Provider Demographics
NPI:1710120761
Name:PICKUP, JASON D (DMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:PICKUP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W SEVIER AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3799
Mailing Address - Country:US
Mailing Address - Phone:423-224-3200
Mailing Address - Fax:423-224-3208
Practice Address - Street 1:117 W SEVIER AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3799
Practice Address - Country:US
Practice Address - Phone:423-224-3200
Practice Address - Fax:423-224-3208
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN96131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1532052Medicaid