Provider Demographics
NPI:1093950057
Name:JOHNSON, JASON LEE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15420 SW MICA LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-9307
Mailing Address - Country:US
Mailing Address - Phone:503-453-4991
Mailing Address - Fax:
Practice Address - Street 1:11120 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2021
Practice Address - Country:US
Practice Address - Phone:503-252-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12553171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor