Provider Demographics
NPI:1588361455
Name:MASON, JACOB (PT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MASON
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 1:183 FOX CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-8268
Mailing Address - Country:US
Mailing Address - Phone:678-972-7151
Mailing Address - Fax:
Practice Address - Street 1:35325 DATE PALM DR STE 131
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7031
Practice Address - Country:US
Practice Address - Phone:760-202-0368
Practice Address - Fax:760-770-1973
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCP024998T225100000X
GAPT016440225100000X
CAPT305449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist