Healthcare Provider Details

I. General information

NPI: 1083931000
Provider Name (Legal Business Name): JASON C SHREVE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 MYLAN PARK LN
MORGANTOWN WV
26501-2281
US

IV. Provider business mailing address

460 MYLAN PARK LN
MORGANTOWN WV
26501-2281
US

V. Phone/Fax

Practice location:
  • Phone: 304-997-0644
  • Fax: 304-983-7768
Mailing address:
  • Phone: 304-997-0644
  • Fax: 304-983-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002789
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT002789
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT002789
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: