Provider Demographics
NPI:1821830746
Name:SANSOM, JAYSON ISAAC
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:ISAAC
Last Name:SANSOM
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 1:2219 FANNIN MILL RD
Mailing Address - Street 2:
Mailing Address - City:GRADY
Mailing Address - State:AL
Mailing Address - Zip Code:36036-7126
Mailing Address - Country:US
Mailing Address - Phone:334-590-7034
Mailing Address - Fax:
Practice Address - Street 1:5735 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36613-2842
Practice Address - Country:US
Practice Address - Phone:251-442-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer