Provider Demographics
NPI:1801008172
Name:GRANDEO, JASON ERIC (MPT OCS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ERIC
Last Name:GRANDEO
Suffix:
Gender:M
Credentials:MPT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:142 INGLE PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304
Mailing Address - Country:US
Mailing Address - Phone:703-370-3703
Mailing Address - Fax:
Practice Address - Street 1:5130 WILSON BLVD
Practice Address - Street 2:SUITE B-1
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205
Practice Address - Country:US
Practice Address - Phone:703-527-9557
Practice Address - Fax:703-526-0438
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052029472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA291437OtherBCBS