Provider Demographics
NPI:1427044486
Name:RODEGHERO, JASON (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:RODEGHERO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4364
Mailing Address - Country:US
Mailing Address - Phone:309-661-6260
Mailing Address - Fax:
Practice Address - Street 1:2200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4364
Practice Address - Country:US
Practice Address - Phone:309-661-6260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70013297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K18151Medicare ID - Type Unspecified