Healthcare Provider Details

I. General information

NPI: 1205279643
Provider Name (Legal Business Name): JASON CHARLES HOLMES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 PINCKNEY ST
WHITEVILLE NC
28472-2221
US

IV. Provider business mailing address

1402 PINCKNEY ST
WHITEVILLE NC
28472-2221
US

V. Phone/Fax

Practice location:
  • Phone: 910-642-4245
  • Fax:
Mailing address:
  • Phone: 910-642-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA5110
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: