Provider Demographics
NPI:1487630034
Name:ROBERTS, JASON TREVOR (ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:TREVOR
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:IA
Mailing Address - Zip Code:51462-8418
Mailing Address - Country:US
Mailing Address - Phone:772-559-5703
Mailing Address - Fax:
Practice Address - Street 1:1000 ELYSIAN PARK AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1112
Practice Address - Country:US
Practice Address - Phone:323-224-1500
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 15432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer