Provider Demographics
NPI:1659349769
Name:KING, JASON (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:KING
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 1:770 GAUSE BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2855
Mailing Address - Country:US
Mailing Address - Phone:985-649-9123
Mailing Address - Fax:985-649-9129
Practice Address - Street 1:770 GAUSE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2855
Practice Address - Country:US
Practice Address - Phone:985-649-9123
Practice Address - Fax:985-649-9129
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA06720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
196620Medicare ID - Type Unspecified