Provider Demographics
NPI:1497224604
Name:GARDNER, JIE HAN (MASSAGE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JIE HAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4126
Mailing Address - Country:US
Mailing Address - Phone:510-663-8881
Mailing Address - Fax:
Practice Address - Street 1:614 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4126
Practice Address - Country:US
Practice Address - Phone:510-663-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36708225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist