Provider Demographics
NPI:1104989748
Name:SMITH, JASON M (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 W FOOTHILL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3804
Mailing Address - Country:US
Mailing Address - Phone:909-985-2337
Mailing Address - Fax:909-985-4694
Practice Address - Street 1:299 W FOOTHILL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3804
Practice Address - Country:US
Practice Address - Phone:909-985-2337
Practice Address - Fax:909-985-4694
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT320150Medicare PIN