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General NPI Number Information
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NPI Number | 1902358724
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Entity Type | Individual
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Provider Name | JASON JOHNSON PTA
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Gender | Male
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Dates
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Enumeration Date | 10/27/2016
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 2300 PAVILION DR
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City | KINGSPORT
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State | TN
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Zip | 37660-4622
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Country | US
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Telephone | 423-765-9655
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Fax |
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Provider Business Mailing Address
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Address Line | 303 SHELBY AVE
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City | CHURCH HILL
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State | TN
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Zip | 37642-3156
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Country | US
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Telephone | 423-863-2418
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5187
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License Number State | TN
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