Provider Demographics
NPI:1154938330
Name:ANDERSON, JASON (LMT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ANDERSON
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 1:1621 W LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-6808
Mailing Address - Country:US
Mailing Address - Phone:812-595-9886
Mailing Address - Fax:
Practice Address - Street 1:1621 W LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-6808
Practice Address - Country:US
Practice Address - Phone:812-595-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21907011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist