Provider Demographics
NPI:1487658720
Name:VAN DYKE, JASON P (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:P
Last Name:VAN DYKE
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 1:5395 RUFFIN RD
Mailing Address - Street 2:STE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1338
Mailing Address - Country:US
Mailing Address - Phone:800-219-4419
Mailing Address - Fax:
Practice Address - Street 1:215 S HICKORY ST
Practice Address - Street 2:STE 224
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4393
Practice Address - Country:US
Practice Address - Phone:760-839-2905
Practice Address - Fax:760-839-2901
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 25655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT251550OtherBLUE SHIELD
CAWPT25155AMedicare ID - Type Unspecified
CAOPT251550OtherBLUE SHIELD