MEDICARE: JAISON SEBASTIAN DOCTORATE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT026884	PA

General Provider Information

NPI Number	:	1184102337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAISON SEBASTIAN DOCTORATE

Provider Business Mailing Address
First Line	:	644 GRAND AVE
Second Line	:
City	:	HAVERTOWN
State	:	PA
Zip	:	19083-3224
Country	:	US
Telephone Number	:	484-321-1395
Fax Number	:

Provider Business Practice Location Address
First Line	:	3605 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-2862
Country	:	US
Telephone Number	:	610-876-6180
Fax Number	:	610-876-6130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	12/04/2020

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Directions to “ JAISON SEBASTIAN DOCTORATE” Practice Location

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