Healthcare Provider Details

I. General information

NPI: 1659052736
Provider Name (Legal Business Name): JASON LORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 PARK AVE
CRANSTON RI
02910-3227
US

IV. Provider business mailing address

20335 PATRIOT WAY
WEST GREENWICH RI
02817-6027
US

V. Phone/Fax

Practice location:
  • Phone: 401-396-7649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN04537
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN03515
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: