Provider Demographics
NPI:1669967774
Name:JASON, RICHARD KYLE
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:KYLE
Last Name:JASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14617 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3815
Mailing Address - Country:US
Mailing Address - Phone:216-376-4345
Mailing Address - Fax:
Practice Address - Street 1:14617 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3815
Practice Address - Country:US
Practice Address - Phone:216-376-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty