Healthcare Provider Details

I. General information

NPI: 1922280304
Provider Name (Legal Business Name): JASON GLENN POLK BS, RRT, RCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 82ND ST
LUBBOCK TX
79404-6337
US

IV. Provider business mailing address

517 82ND ST
LUBBOCK TX
79404-6337
US

V. Phone/Fax

Practice location:
  • Phone: 806-745-2551
  • Fax: 806-745-5171
Mailing address:
  • Phone: 806-745-2551
  • Fax: 806-745-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279H0200X
TaxonomyHome Health Registered Respiratory Therapist
License Number57131
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2279H0200X
TaxonomyHome Health Registered Respiratory Therapist
License Number2464
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: