Basic Information
| Provider Information | |||||||||
| NPI: | 1124193172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1309 WOOD MOOR DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604362087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6721 OLD TRAIL RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468092638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604788090 | ||||||||
| FaxNumber: | 2604788089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05007739A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 336013 | 01 | IN | ANTHEM | OTHER |