Healthcare Provider Details

I. General information

NPI: 1831370964
Provider Name (Legal Business Name): JASON ANDREW LA BENNE IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USCG HQ COMDT (CG-1122) 2100 SECOND ST., SW
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

USCG HQ COMDT (CG-1122) 2100 SECOND ST., SW
WASHINGTON DC
20593-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-475-5181
  • Fax: 202-475-5909
Mailing address:
  • Phone: 202-475-5181
  • Fax: 202-475-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: