Provider Demographics
NPI:1891786646
Name:WALLACE, JASON SCOTT (PTA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:SCOTT
Last Name:WALLACE
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 1:4979 BURSON WAY
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-1017
Mailing Address - Country:US
Mailing Address - Phone:805-671-5625
Mailing Address - Fax:
Practice Address - Street 1:2486 N PONDEROSA DR
Practice Address - Street 2:STE D-106
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2376
Practice Address - Country:US
Practice Address - Phone:805-484-5447
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT5146225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant