Provider Demographics
NPI:1609167618
Name:SUTTON, JONATHAN GRANT (LAC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GRANT
Last Name:SUTTON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 SE 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2607
Mailing Address - Country:US
Mailing Address - Phone:910-818-0560
Mailing Address - Fax:
Practice Address - Street 1:917 SW OAK ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2829
Practice Address - Country:US
Practice Address - Phone:910-818-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR154068171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist