Basic Information
| Provider Information | |||||||||
| NPI: | 1306234844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGETO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | COTA/L | ||||||||
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| OtherLastName: | MAGETO | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | ATENGA | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2825 N STATE HIGHWAY 360 | ||||||||
| Address2: | APT 141 | ||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750507842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163058012 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 721 DUNAWAY LN | ||||||||
| Address2: | |||||||||
| City: | AZLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760202605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174442536 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2015 | ||||||||
| LastUpdateDate: | 01/07/2015 | ||||||||
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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 | 224Z00000X | 212165 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.