MEDICARE: JASON STUART KIRK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	007153	CT

General Provider Information

NPI Number	:	1255373734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON STUART KIRK PT

Provider Business Mailing Address
First Line	:	31 OLD ROUTE 7
Second Line	:
City	:	BROOKFIELD
State	:	CT
Zip	:	06804-1714
Country	:	US
Telephone Number	:	203-740-0020
Fax Number	:	203-775-0238

Provider Business Practice Location Address
First Line	:	85 BARNES RD
Second Line	:	SUITE 109
City	:	WALLINGFORD
State	:	CT
Zip	:	06492-1832
Country	:	US
Telephone Number	:	203-697-1067
Fax Number	:	203-284-0492

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	07/08/2007

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