Provider Demographics
NPI:1831679042
Name:POOLE, JASON BLAKE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BLAKE
Last Name:POOLE
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:PO BOX 1436
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-1436
Mailing Address - Country:US
Mailing Address - Phone:440-858-7623
Mailing Address - Fax:
Practice Address - Street 1:2420 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4954
Practice Address - Country:US
Practice Address - Phone:440-997-2262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2023-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily