Basic Information
| Provider Information | |||||||||
| NPI: | 1174055529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUEVARA | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 796 FREDERICK CT | ||||||||
| Address2: | |||||||||
| City: | SOUTH LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450651393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134318549 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6730 ROOSEVELT AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450055730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132798035 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2017 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 434495 | OH | N | Nursing Service Providers | Registered Nurse | 363LP0808X | APRN.CNP.0029442 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.