=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154179935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JAMISON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2024
-----------------------------------------------------
Last Update Date | 05/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 COURT ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-354-6685
-----------------------------------------------------
Fax | 740-876-4005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 COURT ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-354-6685
-----------------------------------------------------
Fax | 740-876-4005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 4007559
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------