Provider Demographics
NPI:1861644056
Name:POLICARPO, JASON (PTA, RN)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:POLICARPO
Suffix:
Gender:M
Credentials:PTA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 PLYMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-6890
Mailing Address - Country:US
Mailing Address - Phone:856-686-4849
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:610-834-7525
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE005949L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant