Provider Demographics
NPI:1710633250
Name:GOHR, JASON ANDREW
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:GOHR
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 1:1263 OTTAWA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-2017
Mailing Address - Country:US
Mailing Address - Phone:612-239-0193
Mailing Address - Fax:
Practice Address - Street 1:1263 OTTAWA AVE
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-2017
Practice Address - Country:US
Practice Address - Phone:612-239-0193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT020254820802253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency