Basic Information
| Provider Information | |||||||||
| NPI: | 1720354889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELANEY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 TALON DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186328211 | ||||||||
| FaxNumber: | 6186280883 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 PROFESSIONAL PARK DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182053655 | ||||||||
| FaxNumber: | 6186280883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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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 | 070011363 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1720354889 | 01 | IL | BCBS | OTHER |