Provider Demographics
NPI:1770966202
Name:RICHARD, JASON (CRNP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:RICHARD
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 E LEE ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2368
Mailing Address - Country:US
Mailing Address - Phone:334-348-8818
Mailing Address - Fax:334-393-8773
Practice Address - Street 1:805 E LEE ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2368
Practice Address - Country:US
Practice Address - Phone:334-348-8818
Practice Address - Fax:334-393-8773
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-133901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily