Provider Demographics
NPI:1457530537
Name:MALAVOLTA, JASON A (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:MALAVOLTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 WEST BALTIMORE PIKE
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390
Practice Address - Country:US
Practice Address - Phone:610-869-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019017225100000X
DEJ10002349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
94266301OtherCARE FIRST OF MD
1457530537OtherCHAMPUS TRICARE
5070-0104OtherGHMSI
1457530537OtherIBC AMERIHEALTH
2045293OtherPABS
PA233254VKFMedicare PIN
94266301OtherCARE FIRST OF MD
1457530537OtherIBC AMERIHEALTH
1457530537OtherCHAMPUS TRICARE