Provider Demographics
NPI:1356890925
Name:MORENO, JASON ANGEL
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ANGEL
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-1614
Mailing Address - Country:US
Mailing Address - Phone:956-362-3960
Mailing Address - Fax:956-362-3965
Practice Address - Street 1:131 N FM 3167 STE B
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-7009
Practice Address - Country:US
Practice Address - Phone:956-362-3960
Practice Address - Fax:956-362-3965
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1248327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist