Provider Demographics
NPI:1366675084
Name:METROCK, JAISON (ITDS, COTA, SLPA)
Entity type:Individual
Prefix:
First Name:JAISON
Middle Name:
Last Name:METROCK
Suffix:
Gender:M
Credentials:ITDS, COTA, SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 NW 143RD WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-3009
Mailing Address - Country:US
Mailing Address - Phone:954-554-1633
Mailing Address - Fax:
Practice Address - Street 1:1674 NW 143RD WAY
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-3009
Practice Address - Country:US
Practice Address - Phone:954-554-1633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist