Provider Demographics
NPI:1053418087
Name:HIATT, JASON TRAVIS (MPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TRAVIS
Last Name:HIATT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 ABERDEEN CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3175
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-991-9484
Practice Address - Street 1:1952 ABERDEEN CT
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3175
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-748-3014
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015322225100000X
IL070-0153222251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist