Provider Demographics
NPI:1790826675
Name:MOORE, JASON WAYNE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:WAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2150 STATE ROUTE 187
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9625
Mailing Address - Country:US
Mailing Address - Phone:740-852-6926
Mailing Address - Fax:
Practice Address - Street 1:2021 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-9094
Practice Address - Country:US
Practice Address - Phone:740-333-7848
Practice Address - Fax:740-333-1212
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT9304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2572943Medicaid
OH2572943Medicaid