Provider Demographics
NPI:1033892641
Name:HEROLD, JASON DAVID
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:HEROLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 295TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:IA
Mailing Address - Zip Code:52144-7448
Mailing Address - Country:US
Mailing Address - Phone:563-412-9928
Mailing Address - Fax:
Practice Address - Street 1:1445 295TH AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:IA
Practice Address - Zip Code:52144-7448
Practice Address - Country:US
Practice Address - Phone:563-412-9928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1329812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty