Provider Demographics
NPI:1346233152
Name:MULHOLLAND, JASON (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MULHOLLAND
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2885 COUNTY ROAD 214
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-9009
Mailing Address - Country:US
Mailing Address - Phone:573-335-5805
Mailing Address - Fax:
Practice Address - Street 1:602 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6264
Practice Address - Country:US
Practice Address - Phone:618-242-1100
Practice Address - Fax:618-244-5147
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040309992255A2300X
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer