Provider Demographics
NPI:1487746137
Name:HAFNER, JASON J (PT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:HAFNER
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 1:2710 ROCK SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-9356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23915 W MAIN ST
Practice Address - Street 2:SUITES A&B
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-1967
Practice Address - Country:US
Practice Address - Phone:815-609-0570
Practice Address - Fax:815-609-1026
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216860002Medicare PIN
ILK51545Medicare PIN
IL216859004Medicare PIN
ILK53278Medicare PIN
ILK15345Medicare PIN
ILK13472Medicare PIN
ILR03534Medicare PIN
ILP00418843Medicare PIN
IL211585001Medicare PIN
ILK53279Medicare PIN