Healthcare Provider Details

I. General information

NPI: 1285018564
Provider Name (Legal Business Name): JASON DOUGHTY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 BREEZE LANE
CALVERT CITY KY
42029
US

IV. Provider business mailing address

186 BREEZE LN
CALVERT CITY KY
42029
US

V. Phone/Fax

Practice location:
  • Phone: 270-898-2773
  • Fax:
Mailing address:
  • Phone: 270-933-8621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA02674
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: