Provider Demographics
NPI:1689173056
Name:PETERSON, JASON LEE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10857 KUYKENDAHL RD STE 120
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382-2936
Mailing Address - Country:US
Mailing Address - Phone:936-256-3883
Mailing Address - Fax:936-398-6095
Practice Address - Street 1:10857 KUYKENDAHL RD STE 120
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382-2936
Practice Address - Country:US
Practice Address - Phone:815-218-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2133563225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant