Provider Demographics
NPI:1710922950
Name:HALLOCK, JASON S (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:HALLOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 GLENWOOD DRIVE,
Mailing Address - Street 2:SUITE E-487
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-697-0014
Mailing Address - Fax:423-648-6280
Practice Address - Street 1:2525 DESALES AVENUE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-697-0014
Practice Address - Fax:423-648-6280
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1317207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257502672AMedicaid
TN3370172OtherMEDICARE PTAN
TN3664283OtherMEDICARE PTAN
TN3726561OtherMEDICARE PTAN
TN36642831OtherMEDICARE PTAN
TN4116090OtherBCBS OF TENNESSEE
3370172Medicare PIN
TN3370172OtherMEDICARE PTAN