Provider Demographics
NPI:1598994865
Name:PENOLI, JASON MARK (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MARK
Last Name:PENOLI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W WILLIAM CANNON DR
Mailing Address - Street 2:BLDG 1, STE #102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5281
Mailing Address - Country:US
Mailing Address - Phone:512-651-0301
Mailing Address - Fax:512-651-0305
Practice Address - Street 1:2501 W WILLIAM CANNON DR
Practice Address - Street 2:BLDG 1, STE #102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5281
Practice Address - Country:US
Practice Address - Phone:512-651-0301
Practice Address - Fax:512-651-0305
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1189010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX817T85OtherTXBCBS
TX8L21307Medicare PIN
TX00X553Medicare PIN