Provider Demographics
NPI:1164469367
Name:DERRYBERRY, JASON A (MSPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:DERRYBERRY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 NORTH BUFFALO DR
Mailing Address - Street 2:STE 107
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0380
Mailing Address - Country:US
Mailing Address - Phone:702-255-7223
Mailing Address - Fax:702-255-6211
Practice Address - Street 1:911 NORTH BUFFALO DR
Practice Address - Street 2:STE 107
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0380
Practice Address - Country:US
Practice Address - Phone:702-255-7223
Practice Address - Fax:702-255-6211
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV38511Medicare ID - Type Unspecified