Provider Demographics
NPI:1598051112
Name:ABRAHAM, JASEN SISSON (DPT)
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:SISSON
Last Name:ABRAHAM
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 1:670 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3014
Mailing Address - Country:US
Mailing Address - Phone:662-328-1012
Mailing Address - Fax:662-328-1507
Practice Address - Street 1:670 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3014
Practice Address - Country:US
Practice Address - Phone:662-328-1012
Practice Address - Fax:662-328-1507
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00080755Medicaid
MS1598051112OtherNATIONAL PROVIDER NUMBER
MS1598051112OtherNATIONAL PROVIDER NUMBER