Provider Demographics
NPI:1043771207
Name:WASSON, JEFFERSON (DO)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:WASSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10543 KENAI SPUR HWY
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10543 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7812
Practice Address - Country:US
Practice Address - Phone:360-626-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK189244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine