Provider Demographics
NPI:1245256015
Name:GATLIN, JASON CARL (MPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:CARL
Last Name:GATLIN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 TAMARACK DR APT 6
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1983
Mailing Address - Country:US
Mailing Address - Phone:920-279-0320
Mailing Address - Fax:
Practice Address - Street 1:200 EAST TYRANNENA ROAD
Practice Address - Street 2:THERAPY AND SPORT CENTER
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551
Practice Address - Country:US
Practice Address - Phone:920-648-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10409-0242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40472500Medicaid