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: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S EAST ST
WARRENTON MO
63383-2014
US

IV. Provider business mailing address

6 VICTORY DRIVE
LIBERTY MO
64068
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-5454
  • Fax: 636-462-2702
Mailing address:
  • Phone: 816-883-2660
  • Fax: 816-792-9819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: