Provider Demographics
NPI:1457707226
Name:CHARLES, JASON (LMT, LMBT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LMT, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 FOREST AVE
Mailing Address - Street 2:STE 125
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2044
Mailing Address - Country:US
Mailing Address - Phone:646-838-1729
Mailing Address - Fax:
Practice Address - Street 1:1324 FOREST AVE
Practice Address - Street 2:STE 125
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2044
Practice Address - Country:US
Practice Address - Phone:646-838-1729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00810300225700000X
NY030754225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist