Provider Demographics
NPI:1306992367
Name:SUPERNAVAGE, JASON JAMES (MSPT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:JAMES
Last Name:SUPERNAVAGE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1528
Mailing Address - Country:US
Mailing Address - Phone:856-678-8078
Mailing Address - Fax:
Practice Address - Street 1:291 HARDING HWY
Practice Address - Street 2:SUITE A
Practice Address - City:CARNEYS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08069-2229
Practice Address - Country:US
Practice Address - Phone:856-299-9229
Practice Address - Fax:856-299-9226
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01075700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ094714UDHMedicare ID - Type Unspecified