Provider Demographics
NPI:1336603919
Name:STEPAN, JASON RONALD (MPT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:RONALD
Last Name:STEPAN
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 IDYLWILD DR
Mailing Address - Street 2:
Mailing Address - City:SOUR LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77659-5917
Mailing Address - Country:US
Mailing Address - Phone:409-466-2506
Mailing Address - Fax:
Practice Address - Street 1:4025 EASTEX FWY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7146
Practice Address - Country:US
Practice Address - Phone:409-347-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist