Provider Demographics
NPI:1780668574
Name:GRIMES, JASON KEITH (MPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:KEITH
Last Name:GRIMES
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BLAMEY CIR
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-3212
Mailing Address - Country:US
Mailing Address - Phone:203-377-3064
Mailing Address - Fax:
Practice Address - Street 1:27 SIEMON COMPANY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2654
Practice Address - Country:US
Practice Address - Phone:860-274-7573
Practice Address - Fax:860-274-5698
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0074882251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic