Provider Demographics
NPI:1205091410
Name:WILLIS, JASON J (DPM)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6260 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7602
Mailing Address - Country:US
Mailing Address - Phone:409-899-1538
Mailing Address - Fax:409-899-2120
Practice Address - Street 1:6260 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7602
Practice Address - Country:US
Practice Address - Phone:409-899-1538
Practice Address - Fax:409-899-2120
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008018676213ES0103X
TX1988213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery