Provider Demographics
NPI:1427246313
Name:LEDWAK, JASON MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:LEDWAK
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 1:4081 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-8375
Mailing Address - Country:US
Mailing Address - Phone:704-691-1016
Mailing Address - Fax:
Practice Address - Street 1:2300 ABERDEEN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0613
Practice Address - Country:US
Practice Address - Phone:704-834-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist