Provider Demographics
NPI:1083376396
Name:EZZY, JASON ISHMAEL (LMT, AHS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ISHMAEL
Last Name:EZZY
Suffix:
Gender:M
Credentials:LMT, AHS
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:LESALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT, AHS
Mailing Address - Street 1:365 MAIN ST APT 102
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-6304
Mailing Address - Country:US
Mailing Address - Phone:207-449-2847
Mailing Address - Fax:
Practice Address - Street 1:1717 CONGRESS ST STE 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1983
Practice Address - Country:US
Practice Address - Phone:207-449-2847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist