Provider Demographics
NPI:1053903278
Name:PENNELLA, JASON LOUIS (ATC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:LOUIS
Last Name:PENNELLA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 CANAAN RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06068-1602
Mailing Address - Country:US
Mailing Address - Phone:315-323-4566
Mailing Address - Fax:
Practice Address - Street 1:251 CANAAN RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:CT
Practice Address - Zip Code:06068-1602
Practice Address - Country:US
Practice Address - Phone:315-323-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CT0010702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer