Provider Demographics
NPI:1104562701
Name:DEGRAFF, JASON WILLIAM (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:WILLIAM
Last Name:DEGRAFF
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 S BURLINGTON AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-5211
Mailing Address - Country:US
Mailing Address - Phone:816-551-7261
Mailing Address - Fax:
Practice Address - Street 1:1520 MADISON ST APT 108
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-4507
Practice Address - Country:US
Practice Address - Phone:816-551-7261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-07
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95165644163W00000X
CA95029925363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse