Provider Demographics
NPI:1912031022
Name:HOGAN, JASON LEE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:HOGAN
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 1:4530 NORTHERN SKY DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8534
Mailing Address - Country:US
Mailing Address - Phone:701-751-6336
Mailing Address - Fax:701-751-6337
Practice Address - Street 1:4530 NORTHERN SKY DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-751-6336
Practice Address - Fax:701-751-6337
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1327225100000X
MN7874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1464160Medicaid
ND24625OtherBLUE CROSS BLUE SHIELD
MN861347800Medicaid
ND24625OtherBLUE CROSS BLUE SHIELD
ND54853Medicaid