Provider Demographics
NPI:1285194233
Name:DAVIDSON, JASON BRANT
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BRANT
Last Name:DAVIDSON
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 1:36205 KETCHUM RD
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36205 KETCHUM RD
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7553
Practice Address - Country:US
Practice Address - Phone:951-544-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA771967163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse