Provider Demographics
NPI:1144402462
Name:ROY, JASON DEAN (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:ROY
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 1:1900 STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-1116
Mailing Address - Country:US
Mailing Address - Phone:618-826-4588
Mailing Address - Fax:618-826-1579
Practice Address - Street 1:1900 STATE ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1116
Practice Address - Country:US
Practice Address - Phone:618-826-4588
Practice Address - Fax:618-826-1579
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist