=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073822292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON DANIEL BJALME DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2010
-----------------------------------------------------
Last Update Date | 04/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9045 LA FONTANA BLVD SUITE 113
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33434-5636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-482-8007
-----------------------------------------------------
Fax | 561-451-2365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2070 HOMEWOOD BLVD APT 103
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33445-8210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-272-6430
-----------------------------------------------------
Fax | 561-404-0570
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 25862
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------