Provider Demographics
NPI:1144744152
Name:PEDERSEN, JASON W (DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33730 VIA SAN ANGELO DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-3756
Mailing Address - Country:US
Mailing Address - Phone:440-934-6135
Mailing Address - Fax:440-934-6147
Practice Address - Street 1:1380 TULIP ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3157
Practice Address - Country:US
Practice Address - Phone:303-485-4163
Practice Address - Fax:303-485-4164
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087613225100000X
COPTL.0016232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist