Healthcare Provider Details

I. General information

NPI: 1326131137
Provider Name (Legal Business Name): JAMISON MARK GOULD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 11/17/2022
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S WASHINGTON AVE
SAGINAW MI
48601-2551
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 989-776-8000
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11073
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704194062
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: