Provider Demographics
NPI:1063631067
Name:GROENE, JASON JEROME (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:JEROME
Last Name:GROENE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2796 HIGHWAY T
Mailing Address - Street 2:
Mailing Address - City:KOELTZTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:65048-2022
Mailing Address - Country:US
Mailing Address - Phone:573-728-9860
Mailing Address - Fax:
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist