Provider Demographics
NPI:1114972775
Name:PUTZ, JASON JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:JOHN
Last Name:PUTZ
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 1:1129 11TH ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DYERSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52040
Mailing Address - Country:US
Mailing Address - Phone:563-875-8615
Mailing Address - Fax:563-875-8722
Practice Address - Street 1:1129 11TH ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040
Practice Address - Country:US
Practice Address - Phone:563-875-8615
Practice Address - Fax:563-875-8722
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1209163Medicaid
IA35223OtherBLUE SHIELD PROVIDER #
IA35223OtherBLUE SHIELD PROVIDER #