Provider Demographics
NPI:1609197870
Name:BETTENCOURT, JASON (LMT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:BETTENCOURT
Suffix:
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 1:6 MOULTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2524
Mailing Address - Country:US
Mailing Address - Phone:978-998-9993
Mailing Address - Fax:
Practice Address - Street 1:15 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-5429
Practice Address - Country:US
Practice Address - Phone:978-998-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7006175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath