Provider Demographics
NPI:1437274735
Name:GREENE, JASON PAUL (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:GREENE
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 1:3143 NINETY RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-9607
Mailing Address - Country:US
Mailing Address - Phone:614-378-8622
Mailing Address - Fax:
Practice Address - Street 1:15435 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-4827
Practice Address - Country:US
Practice Address - Phone:440-887-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04920225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant