Provider Demographics
NPI:1194485698
Name:WHEATLEY, JASON (ATC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WHITE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-3018
Mailing Address - Country:US
Mailing Address - Phone:315-719-3070
Mailing Address - Fax:
Practice Address - Street 1:10529 SOUTH RIVA RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-774-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program