Provider Demographics
NPI:1295096196
Name:WHITE, JASON A (DPT)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:A
Last Name:WHITE
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 1:35 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2759
Mailing Address - Country:US
Mailing Address - Phone:203-422-0679
Mailing Address - Fax:203-422-0913
Practice Address - Street 1:333 POST RD W
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4701
Practice Address - Country:US
Practice Address - Phone:203-422-0679
Practice Address - Fax:203-422-0913
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14.009619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080009619CT02OtherANTHEM BLUECROSS & BLUESHIELD
CT8049282Medicaid
CTD400082666Medicare UPIN