Provider Demographics
NPI:1609444579
Name:PADGETT, JASON (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PADGETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAIN ST # 891
Mailing Address - Street 2:
Mailing Address - City:PANAMA
Mailing Address - State:IL
Mailing Address - Zip Code:62077-4448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST # 891
Practice Address - Street 2:
Practice Address - City:PANAMA
Practice Address - State:IL
Practice Address - Zip Code:62077-4448
Practice Address - Country:US
Practice Address - Phone:217-556-6879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004980225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant