Provider Demographics
NPI:1508829649
Name:TERRY, JASON JOHN (ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JOHN
Last Name:TERRY
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4302
Mailing Address - Country:US
Mailing Address - Phone:920-860-1269
Mailing Address - Fax:
Practice Address - Street 1:1650 S 41ST ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-7316
Practice Address - Country:US
Practice Address - Phone:920-320-3124
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI646-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer