Provider Demographics
NPI:1538380506
Name:MAILLOUX, JASON W (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 E MAIN ST STE 3100
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1246
Mailing Address - Country:US
Mailing Address - Phone:614-866-8077
Mailing Address - Fax:614-866-9752
Practice Address - Street 1:8050 E MAIN ST STE 3100
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1246
Practice Address - Country:US
Practice Address - Phone:614-866-8077
Practice Address - Fax:614-866-9752
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-089449208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2741662Medicaid