Provider Demographics
NPI:1396096327
Name:SHALLOW, JASON (MPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SHALLOW
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:FLORA
Other - Middle Name:FRANCES
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:50912 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3134
Practice Address - Country:US
Practice Address - Phone:586-200-6603
Practice Address - Fax:586-200-6604
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010038225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750036Medicare PIN
MIMI6211041Medicare PIN