Provider Demographics
NPI:1336604305
Name:KASEY, JEDIDIAH DONALD (PTA)
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:DONALD
Last Name:KASEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 YALE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2030
Mailing Address - Country:US
Mailing Address - Phone:502-648-7369
Mailing Address - Fax:
Practice Address - Street 1:824 S SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-3022
Practice Address - Country:US
Practice Address - Phone:218-998-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03826225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant