Basic Information
Provider Information | |||||||||
NPI: | 1598969842 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONGORIA | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | ARTURO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7808 CLODUS FIELDS DR | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752512206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9725667260 | ||||||||
FaxNumber: | 9725666237 | ||||||||
Practice Location | |||||||||
Address1: | 7808 CLODUS FIELDS DR | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752512206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9725667260 | ||||||||
FaxNumber: | 9725666237 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2007 | ||||||||
LastUpdateDate: | 11/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N2630 | TX | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 204358001 | 05 | TX |   | MEDICAID | BP1-0022492 | 01 |   | INSTITUTIONAL PERMIT | OTHER |