Provider Demographics
NPI:1699159178
Name:EVERSOLE, JASON MACK (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MACK
Last Name:EVERSOLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 E RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:MANCOS
Practice Address - State:CO
Practice Address - Zip Code:81328-9329
Practice Address - Country:US
Practice Address - Phone:970-533-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10054761 594751207Q00000X
UT13605156-1204207Q00000X
FLOS20803207Q00000X
TXR1949207Q00000X
CODR.0060930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine