Provider Demographics
NPI:1447208806
Name:JASKER, BRYAN D (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:D
Last Name:JASKER
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 1:1111 TRINITY LN
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8111
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-661-8107
Practice Address - Street 1:1111 TRINITY LN
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8111
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-661-8107
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-014356225100000X
IL070014356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-014356OtherIL LICENSE NO
IL070-014356OtherIL LICENSE NO