Provider Demographics
NPI:1366649501
Name:WOLLENBERG, JASON L (OT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:WOLLENBERG
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 MEADOWLARK RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-4556
Mailing Address - Country:US
Mailing Address - Phone:785-537-4610
Mailing Address - Fax:785-537-0930
Practice Address - Street 1:2121 MEADOWLARK RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-4556
Practice Address - Country:US
Practice Address - Phone:785-537-4610
Practice Address - Fax:785-537-0930
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist