Healthcare Provider Details

I. General information

NPI: 1558391367
Provider Name (Legal Business Name): JASON DORRIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W SAINT LOUIS ST STE B
WEST FRANKFORT IL
62896-2047
US

IV. Provider business mailing address

309 W SAINT LOUIS ST STE B
WEST FRANKFORT IL
62896-2047
US

V. Phone/Fax

Practice location:
  • Phone: 618-932-2200
  • Fax:
Mailing address:
  • Phone: 618-932-2200
  • Fax: 618-932-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-002119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: