Provider Demographics
NPI:1780651976
Name:ANDRESON, JOHN JACOB (ATC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JACOB
Last Name:ANDRESON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14545 N FRANK LLOYD WRIGHT BLVD
Mailing Address - Street 2:UNIT 1076
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-8806
Mailing Address - Country:US
Mailing Address - Phone:414-915-0464
Mailing Address - Fax:
Practice Address - Street 1:521 SOUTH RURAL ROAD
Practice Address - Street 2:ARIZONA STATE UNIVERSITY
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281
Practice Address - Country:US
Practice Address - Phone:480-965-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1149174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist