Provider Demographics
NPI:1649621442
Name:LOU, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LOU
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 1:110 LIBERTY ST STE 505
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5674
Mailing Address - Country:US
Mailing Address - Phone:508-565-3055
Mailing Address - Fax:508-894-0757
Practice Address - Street 1:110 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5674
Practice Address - Country:US
Practice Address - Phone:508-565-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.150868208D00000X
MA2916722081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice