Provider Demographics
NPI:1538347844
Name:REESE, JASON MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:REESE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-9719
Mailing Address - Country:US
Mailing Address - Phone:203-627-0047
Mailing Address - Fax:860-714-8096
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-771-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009548363A00000X
CT002041363AS0400X
NJ25MP00773400363A00000X
SD1546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGMedicaid