Provider Demographics
NPI:1841612397
Name:COBB, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:COBB
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 1:2117 BLUE HERON COVE DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4929
Mailing Address - Country:US
Mailing Address - Phone:904-318-1335
Mailing Address - Fax:
Practice Address - Street 1:2117 BLUE HERON COVE DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4929
Practice Address - Country:US
Practice Address - Phone:904-318-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9276019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered