Provider Demographics
NPI:1245845502
Name:KIDD, JASON W (ARPN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:KIDD
Suffix:
Gender:M
Credentials:ARPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 RAY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-1914
Mailing Address - Country:US
Mailing Address - Phone:662-266-5464
Mailing Address - Fax:
Practice Address - Street 1:104 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-5313
Practice Address - Country:US
Practice Address - Phone:662-486-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS894920363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health