Basic Information
| Provider Information | |||||||||
| NPI: | 1184182321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4418 RIDGECOVE DR | ||||||||
| Address2: | |||||||||
| City: | ROWLETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750883128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724631405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 930 W CENTERVILLE RD STE C | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750415854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692918500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 1134229 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225100000X | 1134229 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.