Provider Demographics
NPI:1154512564
Name:HARTOG, JASON P (MPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:HARTOG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6017
Mailing Address - Country:US
Mailing Address - Phone:918-622-4278
Mailing Address - Fax:918-270-2398
Practice Address - Street 1:1486 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-8002
Practice Address - Country:US
Practice Address - Phone:918-825-2333
Practice Address - Fax:918-825-6266
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7783909OtherAETNA
7783909OtherAETNA