Provider Demographics
NPI:1235673716
Name:AITSON, JEREMY (PTA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:AITSON
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 1:3030 NW EXPRESSWAY STE 809
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5466
Mailing Address - Country:US
Mailing Address - Phone:405-917-7160
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY STE 809
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5466
Practice Address - Country:US
Practice Address - Phone:405-917-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1158225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant