Healthcare Provider Details

I. General information

NPI: 1407395262
Provider Name (Legal Business Name): JASON LAMAR EVANS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 CAHABA BEACH RD
BIRMINGHAM AL
35242-5225
US

IV. Provider business mailing address

111 W BRAXTON LN
HENDERSONVILLE TN
37075-1210
US

V. Phone/Fax

Practice location:
  • Phone: 205-421-2088
  • Fax:
Mailing address:
  • Phone: 937-830-7572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22307
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: