Provider Demographics
NPI:1598921553
Name:SHAW, JASON (MPT, DA)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:MPT, DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 322
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0322
Mailing Address - Country:US
Mailing Address - Phone:208-359-2500
Mailing Address - Fax:208-359-2502
Practice Address - Street 1:4542 E 280 N
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5885
Practice Address - Country:US
Practice Address - Phone:208-538-7382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist