Provider Demographics
NPI:1083005086
Name:KING, JASON GUYNES (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:GUYNES
Last Name:KING
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 1:968 HIGHLAND HILLS RD
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-9031
Mailing Address - Country:US
Mailing Address - Phone:662-226-3433
Mailing Address - Fax:
Practice Address - Street 1:968 HIGHLAND HILLS RD
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-9031
Practice Address - Country:US
Practice Address - Phone:662-226-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant