Provider Demographics
NPI:1982611836
Name:ABERG, JASON BROOKS (DPT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:BROOKS
Last Name:ABERG
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 1:1673 W SHORELINE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-343-4700
Mailing Address - Fax:208-343-4706
Practice Address - Street 1:1673 W SHORELINE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-343-4700
Practice Address - Fax:208-343-4706
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT 1648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375990Medicaid
RPT1648OtherSTATE LIC
1655601Medicare ID - Type UnspecifiedPROVIDER
1375990Medicare ID - Type UnspecifiedGROUP