Provider Demographics
NPI:1992009054
Name:CONANT, JONATHAN GLEN (LAC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:GLEN
Last Name:CONANT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 NE 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3650
Mailing Address - Country:US
Mailing Address - Phone:503-998-7852
Mailing Address - Fax:
Practice Address - Street 1:8283 SW BARBUR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2871
Practice Address - Country:US
Practice Address - Phone:503-244-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC153627171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist