Provider Demographics
NPI:1710298161
Name:DAVENPORT, JASON MICAH (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICAH
Last Name:DAVENPORT
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 1:103 N MAIN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2796
Mailing Address - Country:US
Mailing Address - Phone:864-528-5700
Mailing Address - Fax:864-528-5701
Practice Address - Street 1:727 SE MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3247
Practice Address - Country:US
Practice Address - Phone:864-454-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist