Provider Demographics
NPI:1972521904
Name:VEGA, JASON M (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:VEGA
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 1:1910 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3520
Mailing Address - Country:US
Mailing Address - Phone:803-256-4107
Mailing Address - Fax:
Practice Address - Street 1:1910 BLANDING ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3520
Practice Address - Country:US
Practice Address - Phone:803-256-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2368225100000X
SC5601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00346935OtherRAILROAD
MS03274724Medicaid
650000375Medicare ID - Type Unspecified
OTH000Medicare UPIN