Provider Demographics
NPI:1558195917
Name:PROUD, JASON (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PROUD
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 1:135 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6093
Mailing Address - Country:US
Mailing Address - Phone:315-529-9315
Mailing Address - Fax:
Practice Address - Street 1:80 NORWICH NEW LONDON TPKE # 2E
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2527
Practice Address - Country:US
Practice Address - Phone:860-892-8683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052939225100000X
CT014595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist