Provider Demographics
NPI:1407255706
Name:ERICKSON, DAVID JASON I (LMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JASON
Last Name:ERICKSON
Suffix:I
Gender:M
Credentials:LMT
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 304
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-0304
Mailing Address - Country:US
Mailing Address - Phone:406-880-0568
Mailing Address - Fax:
Practice Address - Street 1:36084 CAROLINE LN
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-8442
Practice Address - Country:US
Practice Address - Phone:406-880-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4008225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist