Healthcare Provider Details

I. General information

NPI: 1104562701
Provider Name (Legal Business Name): JASON WILLIAM DEGRAFF AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2022
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 MADISON ST APT 108
OAKLAND CA
94612-4507
US

IV. Provider business mailing address

143 S BURLINGTON AVE APT 207
LOS ANGELES CA
90057-5211
US

V. Phone/Fax

Practice location:
  • Phone: 816-551-7261
  • Fax:
Mailing address:
  • Phone: 816-551-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95165644
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95029925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: