Provider Demographics
NPI:1932300308
Name:CROCKETT, JASON E (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:CROCKETT
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 1:1800 OLD LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9663
Mailing Address - Country:US
Mailing Address - Phone:270-789-2023
Mailing Address - Fax:270-465-5361
Practice Address - Street 1:1800 OLD LEBANON RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9663
Practice Address - Country:US
Practice Address - Phone:270-789-2023
Practice Address - Fax:270-465-5361
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1581DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist