Provider Demographics
NPI:1588936363
Name:WILLIAMS, JASON (PTA, NSCA-CPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PTA, NSCA-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 LANDING DR
Mailing Address - Street 2:2C
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-5017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4215 LANDING DR
Practice Address - Street 2:2C
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-5017
Practice Address - Country:US
Practice Address - Phone:224-688-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7173161008174400000X
IL160004341225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No174400000XOther Service ProvidersSpecialist