Provider Demographics
NPI:1659584589
Name:EVERETT, JASON LYLE SR (MPT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LYLE
Last Name:EVERETT
Suffix:SR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 CARNATION AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3838
Mailing Address - Country:US
Mailing Address - Phone:215-706-0641
Mailing Address - Fax:
Practice Address - Street 1:1515 THE FAIRWAY
Practice Address - Street 2:
Practice Address - City:RYDAL
Practice Address - State:PA
Practice Address - Zip Code:19046-1435
Practice Address - Country:US
Practice Address - Phone:215-885-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011114L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist