Healthcare Provider Details

I. General information

NPI: 1093009672
Provider Name (Legal Business Name): JASON SCOTT COUCH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 07/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 W DUNLAP AVE STE 290 SUITE # 290
PHOENIX AZ
85021-2759
US

IV. Provider business mailing address

3829 E DEWBERRY AVE
MESA AZ
85206-1826
US

V. Phone/Fax

Practice location:
  • Phone: 602-789-0344
  • Fax:
Mailing address:
  • Phone: 480-381-3103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number006693
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number006693
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: