Healthcare Provider Details

I. General information

NPI: 1750320594
Provider Name (Legal Business Name): JASON A DOUGHERTY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 LANCASTER AVE
WILMINGTON DE
19805-5232
US

IV. Provider business mailing address

334 PATRIOT DR
LOGAN TWP NJ
08085-4254
US

V. Phone/Fax

Practice location:
  • Phone: 302-778-0810
  • Fax: 302-778-0812
Mailing address:
  • Phone: 856-241-1970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberJ2-0000625
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: