Provider Demographics
NPI:1811921778
Name:CARLL, JASON (PHYSICAL THERAPIST A)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CARLL
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 LAUREL HEIGHTS DR
Mailing Address - Street 2:#4
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302
Mailing Address - Country:US
Mailing Address - Phone:856-455-9730
Mailing Address - Fax:856-455-5165
Practice Address - Street 1:2848 S DELSEA DR
Practice Address - Street 2:#3
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360
Practice Address - Country:US
Practice Address - Phone:856-696-0404
Practice Address - Fax:856-696-8555
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00177900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant