Provider Demographics
NPI:1376529875
Name:MAHNKE, JASON A (MA, AT,C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:A
Last Name:MAHNKE
Suffix:
Gender:M
Credentials:MA, AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ELYSIAN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-1112
Mailing Address - Country:US
Mailing Address - Phone:702-497-8057
Mailing Address - Fax:323-843-9921
Practice Address - Street 1:4001 26TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-1930
Practice Address - Country:US
Practice Address - Phone:702-497-8057
Practice Address - Fax:323-843-9921
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL627225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner