Basic Information
| Provider Information | |||||||||
| NPI: | 1649429614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUTSELL | ||||||||
| FirstName: | JAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 413 S CENTRAL VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | CENTRAL POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975021511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418999194 | ||||||||
| FaxNumber: | 5418991519 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N 5TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975309659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418999194 | ||||||||
| FaxNumber: | 5418991519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HAS-T-10126936 | OR | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 212936 | 05 | OR | MEDICAID |