Provider Demographics
NPI:1639185168
Name:VILLAREAL, JASON FORTUNO (PT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:FORTUNO
Last Name:VILLAREAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1830
Mailing Address - Country:US
Mailing Address - Phone:503-477-4802
Mailing Address - Fax:503-477-9395
Practice Address - Street 1:1740 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2151
Practice Address - Country:US
Practice Address - Phone:541-266-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT32980AMedicare ID - Type Unspecified