Healthcare Provider Details

I. General information

NPI: 1093075855
Provider Name (Legal Business Name): JASON MICHAEL PETTY HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3823 TURMAN LOOP STE 101
WESLEY CHAPEL FL
33544
US

IV. Provider business mailing address

2314 S. CABIN TERRACE
HOMOSASSA FL
34448
US

V. Phone/Fax

Practice location:
  • Phone: 813-345-8135
  • Fax: 573-755-1080
Mailing address:
  • Phone: 618-803-9230
  • Fax: 573-755-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5043
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2748
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: