Provider Demographics
NPI:1598302366
Name:PETTY, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 PAINTER ST
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-3830
Mailing Address - Country:US
Mailing Address - Phone:276-236-5164
Mailing Address - Fax:
Practice Address - Street 1:1570 W RESERVOIR ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1500
Practice Address - Country:US
Practice Address - Phone:276-228-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001636225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant