Provider Demographics
NPI:1548678139
Name:CLEMONS, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, NP-C
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-0929
Mailing Address - Country:US
Mailing Address - Phone:405-896-8058
Mailing Address - Fax:855-223-1999
Practice Address - Street 1:304 S 29TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2501
Practice Address - Country:US
Practice Address - Phone:058-968-0584
Practice Address - Fax:855-223-1999
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-26
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK73444163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1548678139OtherNPI