Basic Information
| Provider Information | |||||||||
| NPI: | 1184722316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | D'AMICO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | RUSSEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W 5TH ST STE 550 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148344707 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 S GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145677688 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT27519 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.