Provider Demographics
NPI:1376844613
Name:KNICLEY, JASON WILLIAM (DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WILLIAM
Last Name:KNICLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10938 LOUIS DETRICK LN
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:MD
Mailing Address - Zip Code:21770-6030
Mailing Address - Country:US
Mailing Address - Phone:301-992-6797
Mailing Address - Fax:
Practice Address - Street 1:3540 SUGARLOAF PKWY STE D03
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7901
Practice Address - Country:US
Practice Address - Phone:240-341-2198
Practice Address - Fax:240-454-8423
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist