Provider Demographics
NPI:1063062875
Name:WADDLES, JASON (DPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WADDLES
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 1:1132 JONESTOWN LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2996
Mailing Address - Country:US
Mailing Address - Phone:859-447-0620
Mailing Address - Fax:
Practice Address - Street 1:101 EASTSIDE DR STE D
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8763
Practice Address - Country:US
Practice Address - Phone:502-867-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2019119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist