Healthcare Provider Details

I. General information

NPI: 1871867465
Provider Name (Legal Business Name): JASON A DAVISON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GOOD SAMARITAN WAY SUITE 220
MOUNT VERNON IL
62864-2408
US

IV. Provider business mailing address

2 GOOD SAMARITAN WAY SUITE 220
MOUNT VERNON IL
62864-2408
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-3900
  • Fax:
Mailing address:
  • Phone: 618-899-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209009423
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: