Healthcare Provider Details

I. General information

NPI: 1558195917
Provider Name (Legal Business Name): JASON PATRICK PROUD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 FORDHAM DR STE 102
FAYETTEVILLE NC
28304-3774
US

IV. Provider business mailing address

1991 FORDHAM DR STE 102
FAYETTEVILLE NC
28304-3774
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-4653
  • Fax: 910-483-9256
Mailing address:
  • Phone: 910-484-4653
  • Fax: 910-483-9256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT61628802
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP24412
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number052939
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: