Provider Demographics
NPI:1275413924
Name:IPPOLITO, JASON MATTHEW
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:IPPOLITO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:NICHOLE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1603 CAPITOL AVE STE 413C1029
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4569
Mailing Address - Country:US
Mailing Address - Phone:951-640-0321
Mailing Address - Fax:
Practice Address - Street 1:1603 CAPITOL AVE STE 413C1029
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4569
Practice Address - Country:US
Practice Address - Phone:951-640-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies