Provider Demographics
NPI:1154097970
Name:PELLETIER, JASON (PT)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:PELLETIER
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 1:2437 WESTOVER AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2234
Mailing Address - Country:US
Mailing Address - Phone:607-280-4889
Mailing Address - Fax:
Practice Address - Street 1:1100 BROOKWOOD DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4505
Practice Address - Country:US
Practice Address - Phone:607-280-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist