Provider Demographics
NPI:1366555484
Name:COZBY, JASON RICHARD (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:RICHARD
Last Name:COZBY
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 1:500 N ROSEMEAD BLVD
Mailing Address - Street 2:APT 28
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2143
Mailing Address - Country:US
Mailing Address - Phone:562-505-6308
Mailing Address - Fax:
Practice Address - Street 1:1605 HOPE ST
Practice Address - Street 2:STE 100
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2647
Practice Address - Country:US
Practice Address - Phone:562-505-6308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT263652251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT263650OtherBLUE SHIELD
CAWPT26365CMedicare ID - Type Unspecified