Basic Information
| Provider Information | |||||||||
| NPI: | 1851631790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | BC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310901 | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363310901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343936688 | ||||||||
| FaxNumber: | 3343937011 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 E WATTS ST | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363302511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343936688 | ||||||||
| FaxNumber: | 3343937011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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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 | 4170 | AL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 51147100 | 01 | AL | BCBSAL | OTHER | 51147102 | 01 | AL | BCBSAL | OTHER | 51147103 | 01 | AL | BCBSAL | OTHER |