Provider Demographics
NPI:1841892379
Name:OLIVEIRA, JASON SOUZA (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SOUZA
Last Name:OLIVEIRA
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 1:4028 DALE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9561
Mailing Address - Country:US
Mailing Address - Phone:209-312-9739
Mailing Address - Fax:209-312-9747
Practice Address - Street 1:3609 OAKDALE RD STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95357-0718
Practice Address - Country:US
Practice Address - Phone:209-312-9739
Practice Address - Fax:209-312-9747
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist