Provider Demographics
NPI:1861824971
Name:KRETZER, JASON MATTHEW (LMT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:KRETZER
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 1:469 RANCHO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3735
Mailing Address - Country:US
Mailing Address - Phone:423-331-0188
Mailing Address - Fax:
Practice Address - Street 1:2900 NW VINE ST
Practice Address - Street 2:SUTIE B
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-8411
Practice Address - Country:US
Practice Address - Phone:423-331-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14557225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist