Healthcare Provider Details

I. General information

NPI: 1245643048
Provider Name (Legal Business Name): JASON GREGORY LULEJIAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PRUDENTIAL DR STE 510
JACKSONVILLE FL
32207-8207
US

IV. Provider business mailing address

PO BOX 748519
ATLANTA GA
30374-8519
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-3800
  • Fax:
Mailing address:
  • Phone: 904-376-3800
  • Fax: 904-376-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberOS18853
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number297758
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1016675
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS020665
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO217288
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number032.0134177
License Number StateVT
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036166039
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number297758
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberO-1867
License Number StateID
# 10
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MB11880300
License Number StateNJ
# 11
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOP61439144
License Number StateWA
# 12
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0073625
License Number StateCO
# 13
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS18853
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: