Healthcare Provider Details

I. General information

NPI: 1912938234
Provider Name (Legal Business Name): JASON R VANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2137 HEAVENLY VW
OOLTEWAH TN
37363-9488
US

IV. Provider business mailing address

2137 HEAVENLY VW
OOLTEWAH TN
37363-9488
US

V. Phone/Fax

Practice location:
  • Phone: 530-966-5454
  • Fax: 530-872-6653
Mailing address:
  • Phone: 530-966-5454
  • Fax: 530-872-6653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number65025
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number44928
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA60594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: