Provider Demographics
NPI:1013639590
Name:COLSON, JASON SEBASTIAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SEBASTIAN
Last Name:COLSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-1302
Mailing Address - Country:US
Mailing Address - Phone:916-420-2754
Mailing Address - Fax:
Practice Address - Street 1:690 ROUTE 9
Practice Address - Street 2:
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-1409
Practice Address - Country:US
Practice Address - Phone:518-584-8172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011121-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant