Provider Demographics
NPI:1942855465
Name:HEROLDT, JASON THOMAS (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:HEROLDT
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 1:1652 TIPPECANOE CT
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6142
Mailing Address - Country:US
Mailing Address - Phone:219-476-5990
Mailing Address - Fax:
Practice Address - Street 1:1950 45TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3958
Practice Address - Country:US
Practice Address - Phone:219-924-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005949A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant