Provider Demographics
NPI:1013786193
Name:FUNKE, JASON MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:FUNKE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10636 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2141
Mailing Address - Country:US
Mailing Address - Phone:562-753-1750
Mailing Address - Fax:
Practice Address - Street 1:1101 S ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5811
Practice Address - Country:US
Practice Address - Phone:714-937-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305410225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist