Provider Demographics
NPI:1205246006
Name:RUSSELL, JASON (DPT)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:RUSSELL
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 1:703 NW PAR DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-7347
Mailing Address - Country:US
Mailing Address - Phone:816-438-9385
Mailing Address - Fax:
Practice Address - Street 1:3980 SOUTH JACKSON DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-795-1433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist