Healthcare Provider Details

I. General information

NPI: 1578492468
Provider Name (Legal Business Name): JASON DEREK THOBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4998 W BROAD ST STE 104
COLUMBUS OH
43228-1647
US

IV. Provider business mailing address

731 CANONBY PL APT A
COLUMBUS OH
43223-2379
US

V. Phone/Fax

Practice location:
  • Phone: 888-890-3779
  • Fax:
Mailing address:
  • Phone: 614-674-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.007823
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: