Provider Demographics
NPI:1457695652
Name:STEVENS, JASON (MA, RD, CSO, LD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MA, RD, CSO, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 W PITTSBURG ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9011
Mailing Address - Country:US
Mailing Address - Phone:918-884-8561
Mailing Address - Fax:
Practice Address - Street 1:3206 W PITTSBURG ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9011
Practice Address - Country:US
Practice Address - Phone:918-884-8561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered