Provider Demographics
NPI:1083748784
Name:JONSON, COURTNEY BLAIRE (LAC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BLAIRE
Last Name:JONSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 620656
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-0656
Mailing Address - Country:US
Mailing Address - Phone:650-346-8732
Mailing Address - Fax:
Practice Address - Street 1:884 PORTOLA ROAD
Practice Address - Street 2:SUITE A-5
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-8633
Practice Address - Country:US
Practice Address - Phone:650-346-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU 768171100000X
CAAC 10371171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist