Provider Demographics
NPI:1750320594
Name:DOUGHERTY, JASON A (PTA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:A
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-4254
Mailing Address - Country:US
Mailing Address - Phone:856-241-1970
Mailing Address - Fax:
Practice Address - Street 1:2801 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-5232
Practice Address - Country:US
Practice Address - Phone:302-778-0810
Practice Address - Fax:302-778-0812
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000625225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant