Provider Demographics
NPI:1184722316
Name:D'AMICO, JASON RUSSEL (LPT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:RUSSEL
Last Name:D'AMICO
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W 5TH ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4519
Mailing Address - Country:US
Mailing Address - Phone:714-834-4707
Mailing Address - Fax:
Practice Address - Street 1:1030 W WARNER AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-3147
Practice Address - Country:US
Practice Address - Phone:714-834-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
CAPT27519167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Single Specialty