Provider Demographics
NPI:1639319924
Name:ANDERSON, JASON WILLIAM (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:WILLIAM
Last Name:ANDERSON
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 1:4704 SEASHORE DR
Mailing Address - Street 2:APT B
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2524
Mailing Address - Country:US
Mailing Address - Phone:401-595-4076
Mailing Address - Fax:
Practice Address - Street 1:1640 NEWPORT BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-650-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist