Provider Demographics
NPI:1124193172
Name:SIMS, JASON L (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:L
Last Name:SIMS
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 1:1309 WOOD MOOR DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1425
Mailing Address - Country:US
Mailing Address - Phone:260-436-2087
Mailing Address - Fax:
Practice Address - Street 1:6721 OLD TRAIL RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-2638
Practice Address - Country:US
Practice Address - Phone:260-478-8090
Practice Address - Fax:260-478-8089
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007739A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN336013OtherANTHEM
IN336013OtherANTHEM