Provider Demographics
NPI:1457121956
Name:ZELLERS, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ZELLERS
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 1:1004 4 MILE RD NW APT 1A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-1560
Mailing Address - Country:US
Mailing Address - Phone:616-719-9277
Mailing Address - Fax:
Practice Address - Street 1:410 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6649
Practice Address - Country:US
Practice Address - Phone:517-882-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5302416935183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program