Provider Demographics
NPI:1124345616
Name:WAYRYNEN, JASON LEE PAUL (BS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LEE PAUL
Last Name:WAYRYNEN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 N CARPENTER RD STE 12
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-1215
Mailing Address - Country:US
Mailing Address - Phone:605-360-5360
Mailing Address - Fax:
Practice Address - Street 1:1219 N CARPENTER RD STE 12
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351
Practice Address - Country:US
Practice Address - Phone:209-569-0713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA798841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator