Provider Demographics
NPI:1740970961
Name:METTLACH, JASON (DPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:METTLACH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 SUNRISE BAY RD
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4270
Mailing Address - Country:US
Mailing Address - Phone:920-851-3905
Mailing Address - Fax:
Practice Address - Street 1:4554 FORESTDALE DR UNIT C16
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-1392
Practice Address - Country:US
Practice Address - Phone:435-494-1336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist