Healthcare Provider Details

I. General information

NPI: 1013786193
Provider Name (Legal Business Name): JASON MATTHEW FUNKE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 WILLIAMS DR
GEORGETOWN TX
78633-2044
US

IV. Provider business mailing address

3474 TAHITIAN PL
LAKE HAVASU CITY AZ
86406-6374
US

V. Phone/Fax

Practice location:
  • Phone: 512-713-0521
  • Fax: 737-701-5871
Mailing address:
  • Phone: 562-753-1750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP061699T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: