Provider Demographics
NPI:1811271687
Name:JASA, ADAM DOUGLAS
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:DOUGLAS
Last Name:JASA
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 1:1421 GUERNEVILLE RD
Mailing Address - Street 2:224
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7220
Mailing Address - Country:US
Mailing Address - Phone:707-544-4433
Mailing Address - Fax:
Practice Address - Street 1:1421 GUERNEVILLE RD
Practice Address - Street 2:224
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7220
Practice Address - Country:US
Practice Address - Phone:707-544-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7671237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist