Provider Demographics
NPI:1851420558
Name:STEPHENS, JASON (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:STEPHENS
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 1:21438 NAUTIQUE BOULAVARD # 302
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031
Mailing Address - Country:US
Mailing Address - Phone:706-466-2727
Mailing Address - Fax:704-323-7144
Practice Address - Street 1:550 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2876
Practice Address - Country:US
Practice Address - Phone:706-466-2727
Practice Address - Fax:704-323-7144
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426614Medicare Oscar/Certification