1609861608 NPI number — JASON JAHN O.D.

Table of content: JASON JAHN O.D. (NPI 1609861608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609861608 NPI number — JASON JAHN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAHN
Provider First Name:
JASON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1609861608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1208 22ND AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57006-0284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-692-2020
Provider Business Mailing Address Fax Number:
605-692-9594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1208 22ND AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57006-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-692-2020
Provider Business Practice Location Address Fax Number:
605-692-9594
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  142 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22104 . This is a "SIOUX VALLEY HEALTH" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0073102 . This is a "BCBS OF SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4C035JA . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00815934 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9280170 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 419 . This is a "DAKOTA CARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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