Provider Demographics
NPI:1366403933
Name:COLLIN, JASON SCOTT (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:COLLIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 DUNLAP DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6448
Mailing Address - Country:US
Mailing Address - Phone:530-208-9910
Mailing Address - Fax:530-285-2001
Practice Address - Street 1:2050 DUNLAP DR
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6448
Practice Address - Country:US
Practice Address - Phone:530-208-9910
Practice Address - Fax:530-285-2001
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2315225100000X
CA27310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT27310AMedicare ID - Type Unspecified