Provider Demographics
NPI:1689057770
Name:STEWART, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69004
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-9004
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY # 71
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA8235225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant