Healthcare Provider Details

I. General information

NPI: 1154958957
Provider Name (Legal Business Name): JASON FARRIS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 05/21/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDDAC-BAVARIA PSC 411 UNIT 28037
APO AE
09122
US

IV. Provider business mailing address

4348 ASPEN DR
MANHATTAN KS
66502-8706
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2491
  • Fax:
Mailing address:
  • Phone: 801-499-7629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9454013-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: