Provider Demographics
NPI:1750687240
Name:BRISSON, JASEN (MSPT)
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:
Last Name:BRISSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 DURHAM RD STE 110
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-8793
Mailing Address - Country:US
Mailing Address - Phone:919-570-7080
Mailing Address - Fax:
Practice Address - Street 1:843 DURHAM RD STE 110
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-8793
Practice Address - Country:US
Practice Address - Phone:919-570-7080
Practice Address - Fax:919-570-7081
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10717OtherNC PHYSICAL THERAPY LICENSE