1518268887 NPI number — JASON LOVELL

Table of content: SUSAN LYNN SHOOBE PSY.D. (NPI 1881774453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518268887 NPI number — JASON LOVELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JASON LOVELL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518268887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1783
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82501-0235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-253-4103
Provider Business Mailing Address Fax Number:
801-253-0942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
716 COLLEGE VIEW DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
RIVERTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82501-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-857-4969
Provider Business Practice Location Address Fax Number:
307-856-3883
Provider Enumeration Date:
11/03/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LOVELL
Authorized Official First Name:
JASON
Authorized Official Middle Name:
DEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-856-4969

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  7960A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 7960A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1518268887 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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