Basic Information
| Provider Information | |||||||||
| NPI: | 1417069485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | BENNETT | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 PEQUOT CT | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064681296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326187010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 888 WHITE PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066114552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032682882 | ||||||||
| FaxNumber: | 2034523097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 007907 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 007907 | 01 | CT | LICENSE | OTHER |