Provider Demographics
NPI:1861550022
Name:ELENBURG, JASON L (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:ELENBURG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 CLEARVISTA DR
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1621
Mailing Address - Country:US
Mailing Address - Phone:317-621-9292
Mailing Address - Fax:317-621-9299
Practice Address - Street 1:3600 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5407
Practice Address - Country:US
Practice Address - Phone:765-213-3870
Practice Address - Fax:765-213-3888
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005011A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist