Provider Demographics
NPI:1255829859
Name:STENSTROM, JASON JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JAMES
Last Name:STENSTROM
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 1:738 COUNTRY LAKES DR
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-5488
Mailing Address - Country:US
Mailing Address - Phone:901-581-1692
Mailing Address - Fax:
Practice Address - Street 1:738 COUNTRY LAKES DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-5488
Practice Address - Country:US
Practice Address - Phone:901-581-1692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-29
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2129225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant