Healthcare Provider Details

I. General information

NPI: 1831679042
Provider Name (Legal Business Name): JASON BLAKE POOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/13/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 LAKE AVE
ASHTABULA OH
44004-4954
US

IV. Provider business mailing address

PO BOX 1436
ANDOVER OH
44003-1436
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-2262
  • Fax:
Mailing address:
  • Phone: 440-858-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.023883
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: