Provider Demographics
NPI:1912500539
Name:BETHEA, JASON WILLIAM SR (LMT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:WILLIAM
Last Name:BETHEA
Suffix:SR
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:WILLIAM
Other - Last Name:BETHEA
Other - Suffix:SR
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:11 BROADWAY # 433
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-1303
Mailing Address - Country:US
Mailing Address - Phone:646-413-4930
Mailing Address - Fax:
Practice Address - Street 1:11 BROADWAY # 433
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-1303
Practice Address - Country:US
Practice Address - Phone:646-413-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032412225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist