=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366123820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON D CREEK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2023
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5516 BENTGRASS RUN DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-6133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-445-9241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1945 J N PEASE PL STE 201
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-4512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-445-9241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON DEAN CREEK
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 951-445-9241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------