Provider Demographics
NPI:1023272747
Name:MAIN, JASON DONALD (DPT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:DONALD
Last Name:MAIN
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 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:970-493-0521
Practice Address - Street 1:1610 DRY CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6405
Practice Address - Country:US
Practice Address - Phone:720-494-4750
Practice Address - Fax:720-494-4751
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty