Provider Demographics
NPI:1922543131
Name:CROCKETT, JASON WESLEY (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WESLEY
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 LASALLE STREET GSRB1 - 3017 DUMC 103861
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-4070
Mailing Address - Country:US
Mailing Address - Phone:919-668-8108
Mailing Address - Fax:
Practice Address - Street 1:20 DUKE MEDICINE CIRCLE DUKE CANCER CENTER CLINIC 5-1
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710
Practice Address - Country:US
Practice Address - Phone:919-668-8108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-23
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC250967163W00000X
NC5009668363LF0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily