Provider Demographics
NPI:1023560638
Name:MAXWELL, JASON ALAN (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALAN
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 MAPLECREST RD # 112
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1897
Mailing Address - Country:US
Mailing Address - Phone:260-273-1206
Mailing Address - Fax:
Practice Address - Street 1:7525 MAPLECREST RD # 112
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-1897
Practice Address - Country:US
Practice Address - Phone:260-273-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-30
Last Update Date:2016-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005269A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant