Provider Demographics
NPI:1265115547
Name:COTTRELL, JASON LEE
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:COTTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S 8TH AVE STOP 8253
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0002
Mailing Address - Country:US
Mailing Address - Phone:208-282-4726
Mailing Address - Fax:
Practice Address - Street 1:1248 W 300 S
Practice Address - Street 2:
Practice Address - City:PINGREE
Practice Address - State:ID
Practice Address - Zip Code:83262-1122
Practice Address - Country:US
Practice Address - Phone:208-681-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT66258183700000X
363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183700000XPharmacy Service ProvidersPharmacy Technician
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant