Provider Demographics
NPI:1437364379
Name:KEAN, JASON (COTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KEAN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 CHAMPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1617
Mailing Address - Country:US
Mailing Address - Phone:845-665-6795
Mailing Address - Fax:
Practice Address - Street 1:606 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7013
Practice Address - Country:US
Practice Address - Phone:845-665-6795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006416224Z00000X
NY007094224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant