Healthcare Provider Details

I. General information

NPI: 1396263497
Provider Name (Legal Business Name): JASON M LYDELL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 BERGENLINE AVE
WEST NEW YORK NJ
07093-1704
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 201-758-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01752500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: