Provider Demographics
NPI:1407132558
Name:DAUGHERTY, JASON KYLE (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:KYLE
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13385 FM 3039
Mailing Address - Street 2:
Mailing Address - City:CRANDALL
Mailing Address - State:TX
Mailing Address - Zip Code:75114-4818
Mailing Address - Country:US
Mailing Address - Phone:972-427-6150
Mailing Address - Fax:972-427-6133
Practice Address - Street 1:13385 FM 3039
Practice Address - Street 2:
Practice Address - City:CRANDALL
Practice Address - State:TX
Practice Address - Zip Code:75114-4818
Practice Address - Country:US
Practice Address - Phone:972-427-6150
Practice Address - Fax:972-427-6133
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT26382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer