Provider Demographics
NPI:1093086209
Name:OLIVER, JASON MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:OLIVER
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 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-483-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603190225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant