Provider Demographics
NPI:1700353570
Name:PATULOT, RENJASON C (MA)
Entity type:Individual
Prefix:MR
First Name:RENJASON
Middle Name:C
Last Name:PATULOT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E COOLBAUGH ST APT 301
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-2359
Mailing Address - Country:US
Mailing Address - Phone:267-423-3456
Mailing Address - Fax:
Practice Address - Street 1:2301 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1305
Practice Address - Country:US
Practice Address - Phone:712-623-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093927235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist