Provider Demographics
NPI:1245557529
Name:BORN, JASON EDWARD (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:BORN
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 1:1101 LYNDON LN
Mailing Address - Street 2:
Mailing Address - City:LYNDON
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 LYNDON LN
Practice Address - Street 2:
Practice Address - City:LYNDON
Practice Address - State:KY
Practice Address - Zip Code:40222-4317
Practice Address - Country:US
Practice Address - Phone:502-425-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06001784A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant