Provider Demographics
NPI:1043651771
Name:HEROLD, JASON (DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HEROLD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3827
Mailing Address - Country:US
Mailing Address - Phone:970-691-5252
Mailing Address - Fax:
Practice Address - Street 1:4460 S NOLAND RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-4743
Practice Address - Country:US
Practice Address - Phone:816-373-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013023642225100000X
KS11-04610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist