Provider Demographics
NPI:1114736592
Name:VERDISCO, JASON ROBERT (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:VERDISCO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PARK AVE APT 91
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2405
Mailing Address - Country:US
Mailing Address - Phone:631-258-4821
Mailing Address - Fax:
Practice Address - Street 1:405 E 75TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3102
Practice Address - Country:US
Practice Address - Phone:646-714-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02291100225100000X
NY053306-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist