Provider Demographics
NPI:1316051188
Name:GREEN, JASON ROBERT (MSPT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:GREEN
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 1:17 BOLLING CIR
Mailing Address - Street 2:
Mailing Address - City:CHADDS FORD
Mailing Address - State:PA
Mailing Address - Zip Code:19317-9023
Mailing Address - Country:US
Mailing Address - Phone:610-361-8972
Mailing Address - Fax:
Practice Address - Street 1:62 ROCKFORD RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1047
Practice Address - Country:US
Practice Address - Phone:302-428-1021
Practice Address - Fax:302-428-1034
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001762225100000X
PAPT016314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000030575Medicaid
DE1000030575Medicaid