Provider Demographics
NPI:1922374818
Name:BERG, JASON THOMAS (MSPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:BERG
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:1125 FORREST AVE STE 101
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3483
Practice Address - Country:US
Practice Address - Phone:302-735-4900
Practice Address - Fax:302-735-4900
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0014240225100000X
FLPT 27059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT27059OtherPHYSICAL THERAPY