Provider Demographics
NPI:1487963302
Name:KAWADLER, JAESON BRYAN (DPT, CSCS)
Entity type:Individual
Prefix:
First Name:JAESON
Middle Name:BRYAN
Last Name:KAWADLER
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 W BROADWAY
Mailing Address - Street 2:APT 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1938
Mailing Address - Country:US
Mailing Address - Phone:508-932-6254
Mailing Address - Fax:
Practice Address - Street 1:49 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2817
Practice Address - Country:US
Practice Address - Phone:508-580-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist