Provider Demographics
NPI:1710351671
Name:GOODBRAKE, JASON (CMT, SI)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GOODBRAKE
Suffix:
Gender:M
Credentials:CMT, SI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 CHAIN BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1485 CHAIN BRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4513
Practice Address - Country:US
Practice Address - Phone:334-301-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019007563225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist