Basic Information
| Provider Information | |||||||||
| NPI: | 1316051188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 BOLLING CIR | ||||||||
| Address2: | |||||||||
| City: | CHADDS FORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193179023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103618972 | ||||||||
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| Practice Location | |||||||||
| Address1: | 62 ROCKFORD RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198061047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024281021 | ||||||||
| FaxNumber: | 3024281034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| 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 | J10001762 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT016314 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1000030575 | 05 | DE | MEDICAID |