Provider Demographics
NPI:1164644407
Name:KOLLER, JASON J (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:KOLLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 NORMA PL
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-1097
Mailing Address - Country:US
Mailing Address - Phone:732-367-1408
Mailing Address - Fax:
Practice Address - Street 1:3002 ESSEX RD
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-7758
Practice Address - Country:US
Practice Address - Phone:732-643-2000
Practice Address - Fax:732-643-2056
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00177400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant