Provider Demographics
NPI:1518410919
Name:TRAXSON, JASON (ATC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:TRAXSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 S 6TH PL
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9704
Mailing Address - Country:US
Mailing Address - Phone:479-770-0700
Mailing Address - Fax:
Practice Address - Street 1:325 S 6TH PL
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9704
Practice Address - Country:US
Practice Address - Phone:479-770-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT475174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist