Provider Demographics
NPI:1376941674
Name:LLANES, JASON (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LLANES
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 1:718 TENNIE ST
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-2931
Mailing Address - Country:US
Mailing Address - Phone:832-462-9533
Mailing Address - Fax:
Practice Address - Street 1:718 TENNIE ST
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-2931
Practice Address - Country:US
Practice Address - Phone:832-462-9533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2055379225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant