Provider Demographics
NPI:1609604354
Name:DANIEL, JASON JACKSON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:JACKSON
Last Name:DANIEL
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 1:17270 BEAR VALLEY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7751
Mailing Address - Country:US
Mailing Address - Phone:760-245-8828
Mailing Address - Fax:
Practice Address - Street 1:17270 BEAR VALLEY RD STE 105
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7751
Practice Address - Country:US
Practice Address - Phone:760-245-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist