Provider Demographics
NPI:1558681957
Name:HARLESS, JASON W (DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:HARLESS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:10876 ISABELLE DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2097
Practice Address - Country:US
Practice Address - Phone:260-748-2233
Practice Address - Fax:260-748-2277
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010353A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201004810AMedicaid
IN100257920OtherGROUP MEDICAID
IN156546OtherGROUP MEDICARE