Healthcare Provider Details

I. General information

NPI: 1194154526
Provider Name (Legal Business Name): MARYLOU E JASON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4099 STATE HIGHWAY 145
DURHAM NY
12422
US

IV. Provider business mailing address

4099 STATE HIGHWAY 145
DURHAM NY
12422
US

V. Phone/Fax

Practice location:
  • Phone: 518-259-8412
  • Fax: 518-239-5925
Mailing address:
  • Phone: 518-259-8412
  • Fax: 518-239-5925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number401437
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: