Provider Demographics
NPI:1104797679
Name:FISHER, JASON KYLE
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:KYLE
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HALLIGAN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-7659
Mailing Address - Country:US
Mailing Address - Phone:720-345-4876
Mailing Address - Fax:
Practice Address - Street 1:104 S SCHILLER AVE
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NE
Practice Address - Zip Code:69169
Practice Address - Country:US
Practice Address - Phone:720-345-4876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEH14172980374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide