Provider Demographics
NPI:1932657798
Name:CASAZZA, JARED KENNETH (PT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:KENNETH
Last Name:CASAZZA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 FERNCREEK DR
Mailing Address - Street 2:SUITE 801
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2563
Mailing Address - Country:US
Mailing Address - Phone:910-484-2171
Mailing Address - Fax:
Practice Address - Street 1:872 PRICES FORK RD
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-3229
Practice Address - Country:US
Practice Address - Phone:407-392-1615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16639225100000X
VA2305209489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305209489OtherPHYSICAL THERAPY LICENSE