Provider Demographics
NPI:1962479329
Name:LAW, JASON (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LAW
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 1:2211 E BELTLINE AVE NE STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9802
Mailing Address - Country:US
Mailing Address - Phone:616-202-4840
Mailing Address - Fax:
Practice Address - Street 1:2211 E BELTLINE AVE NE STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9802
Practice Address - Country:US
Practice Address - Phone:616-202-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist