MEDICARE: JASON CLYDE LEVEILLE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	172945-30	WI

General Provider Information

NPI Number	:	1053254771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON CLYDE LEVEILLE RN

Provider Business Mailing Address
First Line	:	3812 E 4TH ST
Second Line	:
City	:	SUPERIOR
State	:	WI
Zip	:	54880-4122
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1423 CENTRAL AVE
Second Line	:
City	:	SUPERIOR
State	:	WI
Zip	:	54880-5963
Country	:	US
Telephone Number	:	715-394-8785
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/09/2026

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