Provider Demographics
NPI:1124141486
Name:HARRISON, JASON PAUL (PTA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:PAUL
Last Name:HARRISON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:PAUL
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1203 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-4962
Mailing Address - Country:US
Mailing Address - Phone:405-808-8030
Mailing Address - Fax:
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:SUITE 809
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-917-7160
Practice Address - Fax:406-917-7161
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKTA473225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant