Provider Demographics
NPI:1710460068
Name:GRANT, JAASHA PENA (PT, DPT, WCS)
Entity type:Individual
Prefix:
First Name:JAASHA
Middle Name:PENA
Last Name:GRANT
Suffix:
Gender:F
Credentials:PT, DPT, WCS
Other - Prefix:
Other - First Name:JAASHA
Other - Middle Name:
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-449-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
AZ302932251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic