Provider Demographics
NPI:1386644524
Name:LITTLEDIKE, JASON S (MPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:LITTLEDIKE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 S 400 W
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2053
Mailing Address - Country:US
Mailing Address - Phone:801-798-1626
Mailing Address - Fax:801-798-1236
Practice Address - Street 1:77 S 400 W
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-2053
Practice Address - Country:US
Practice Address - Phone:801-798-1626
Practice Address - Fax:801-798-1236
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT48738752401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3911/870578539003Medicaid
UTQM0000076331OtherALTIUS PROVIDER ID
TX48738752402001OtherWRHN PROVIDER ID
64-00582OtherUNITED HEALTHCARE ID#
UT48738752400001OtherBCBS PROVIDER ID#
UT64411OtherPEHP PROVIDER ID