Provider Demographics
NPI:1255574232
Name:MCCULLEY, JASON (HIS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MCCULLEY
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 S WALNUT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7393
Mailing Address - Country:US
Mailing Address - Phone:812-329-0242
Mailing Address - Fax:
Practice Address - Street 1:3908 S WALNUT ST
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7393
Practice Address - Country:US
Practice Address - Phone:812-329-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001313A235500000X
AR603235500000X
237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist