Provider Demographics
NPI:1962405928
Name:ELLEN, JASON LEE (OD)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEE
Last Name:ELLEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 S. GATEWAY PLACE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037
Mailing Address - Country:US
Mailing Address - Phone:918-747-2020
Mailing Address - Fax:918-747-2056
Practice Address - Street 1:244 S. GATEWAY PLACE
Practice Address - Street 2:SUITE 401
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037
Practice Address - Country:US
Practice Address - Phone:918-747-2020
Practice Address - Fax:918-747-2056
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2060377OtherUNITED HEALTHCARE
OK100761000AMedicaid
OK7518168OtherAETNA
OK410043720Medicare PIN
OK7518168OtherAETNA
OKU80849Medicare UPIN