Healthcare Provider Details

I. General information

NPI: 1972156404
Provider Name (Legal Business Name): JASON KYLE BERRY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 20097
APO AA
28542-0097
US

IV. Provider business mailing address

PSC 20097
APO AA
28542-0097
US

V. Phone/Fax

Practice location:
  • Phone: 910-376-7146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: