Provider Demographics
NPI:1891102133
Name:VARGHESE, JAISON
Entity Type:Individual
Prefix:
First Name:JAISON
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 WESTBROOK
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-8211
Mailing Address - Country:US
Mailing Address - Phone:734-546-7510
Mailing Address - Fax:
Practice Address - Street 1:426 WESTBROOK
Practice Address - Street 2:
Practice Address - City:WHITMORE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48189-8211
Practice Address - Country:US
Practice Address - Phone:734-546-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist