Healthcare Provider Details

I. General information

NPI: 1992079792
Provider Name (Legal Business Name): JASON JEREMY WEBER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 66TH ST N
KENNETH CITY FL
33709-4918
US

IV. Provider business mailing address

337 37TH ST S
ST PETERSBURG FL
33711-1601
US

V. Phone/Fax

Practice location:
  • Phone: 727-546-2405
  • Fax:
Mailing address:
  • Phone: 727-518-4757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA20342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: