Provider Demographics
NPI:1548725344
Name:SWANSON, JASON SCOTT (PTA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-8902
Mailing Address - Country:US
Mailing Address - Phone:502-552-8582
Mailing Address - Fax:
Practice Address - Street 1:900 GAGEL AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4012
Practice Address - Country:US
Practice Address - Phone:502-368-5827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03396225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant