Provider Demographics
NPI:1750684122
Name:WALSTON, JASON (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WALSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 W MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3349
Mailing Address - Country:US
Mailing Address - Phone:615-338-3602
Mailing Address - Fax:
Practice Address - Street 1:386 W MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3349
Practice Address - Country:US
Practice Address - Phone:615-338-3602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist