Provider Demographics
NPI:1134233398
Name:GUARNERI, JASON JACK (MPT, SCS, ATC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:JACK
Last Name:GUARNERI
Suffix:
Gender:M
Credentials:MPT, SCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-9313
Practice Address - Country:US
Practice Address - Phone:610-869-2200
Practice Address - Fax:610-869-2311
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1 - 0001975225100000X
PAPT018523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
91128101OtherCAREFIRST
DE1000036972Medicaid
1134233398OtherCHAMPUS TRICARE
5070-0049OtherCAREFIRST
1990451OtherPABS
2860990000OtherIBC AMERIHEALTH
DEQ52664Medicare UPIN
DE022545A78Medicare PIN
1134233398OtherCHAMPUS TRICARE
PA117512YRN6Medicare PIN