Provider Demographics
NPI:1861217077
Name:VAN GELDER, JASON MICHAEL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:VAN GELDER
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 E BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-7562
Mailing Address - Country:US
Mailing Address - Phone:509-863-5593
Mailing Address - Fax:
Practice Address - Street 1:514 E BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-7562
Practice Address - Country:US
Practice Address - Phone:509-863-5593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61628632363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health