Provider Demographics
NPI:1548735681
Name:KNISLEY, JASON WADE (CMT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:WADE
Last Name:KNISLEY
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 EL CAMINO REAL STE 13A-251
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-2305
Mailing Address - Country:US
Mailing Address - Phone:650-564-3375
Mailing Address - Fax:
Practice Address - Street 1:855 EL CAMINO REAL STE 13A-251
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2305
Practice Address - Country:US
Practice Address - Phone:650-564-3375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist