Basic Information
| Provider Information | |||||||||
| NPI: | 1649621442 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LOU | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 LIBERTY ST STE 505 | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085653055 | ||||||||
| FaxNumber: | 5088940757 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085653055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2016 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 036.150868 | IL | N | Allopathic & Osteopathic Physicians | General Practice | 2081S0010X | 291672 | MA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.