Healthcare Provider Details

I. General information

NPI: 1124356662
Provider Name (Legal Business Name): JASON REID COHEN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2559
US

IV. Provider business mailing address

5800 3RD AVE
BROOKLYN NY
11220-3702
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7425
  • Fax: 718-630-7604
Mailing address:
  • Phone: 718-630-6180
  • Fax: 718-630-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number023418
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: