Basic Information
| Provider Information | |||||||||
| NPI: | 1821223058 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189273226 | ||||||||
| FaxNumber: | 9189273193 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 S COLUMBIA AVE STE LL6 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741143510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188957222 | ||||||||
| FaxNumber: | 9188957223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4238 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200253150A | 05 | OK | MEDICAID |