Healthcare Provider Details

I. General information

NPI: 1144418112
Provider Name (Legal Business Name): JASON L LAND PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 HESTER'S CROSSING
ROUND ROCK TX
78681-8018
US

IV. Provider business mailing address

4515 SETON CENTER PARKWAY SUITE 215-CREDENTIALING
AUSTIN TX
78759-5785
US

V. Phone/Fax

Practice location:
  • Phone: 512-244-9024
  • Fax: 512-460-7342
Mailing address:
  • Phone: 512-231-5506
  • Fax: 512-406-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1157577
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: