Individual
MR. JASON SCOTT WALLACE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
2486 N PONDEROSA DR, STE D-106, CAMARILLO, CA 93010-2376
(805) 484-5447
Mailing address
4979 BURSON WAY, OXNARD, CA 93036-1017
(805) 671-5625
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
AT5146
CA
Other
Enumeration date
11/01/2005
Last updated
07/08/2007
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