Basic Information
| Provider Information | |||||||||
| NPI: | 1497740583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MHS, OTR/L, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2416 HIGHWAY 45 N | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397051320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648866 | ||||||||
| FaxNumber: | 8592641167 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 N EAGLE CREEK DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648866 | ||||||||
| FaxNumber: | 8592641167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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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 | 225XH1200X | R2268 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 000000600569 | 01 | KY | BCBS FOR LHT | OTHER |