Provider Demographics
NPI:1063796589
Name:WEIGOLD, JASON ALAN (COTA/L)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ALAN
Last Name:WEIGOLD
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 QUAKER AVE APT D
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:NY
Mailing Address - Zip Code:13673-3199
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 QUAKER AVE APT D
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:NY
Practice Address - Zip Code:13673-3199
Practice Address - Country:US
Practice Address - Phone:610-217-5359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007956-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant