Provider Demographics
NPI:1093480170
Name:GULSTROM, JASON (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GULSTROM
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 1:20347 TIMBERLAKE RD STE B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7352
Mailing Address - Country:US
Mailing Address - Phone:434-352-5799
Mailing Address - Fax:434-509-1695
Practice Address - Street 1:571 COURT STREET
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-2450
Practice Address - Country:US
Practice Address - Phone:434-352-5799
Practice Address - Fax:434-509-1695
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist