Provider Demographics
NPI:1568687085
Name:CRUZAN, JASON EUGENE (LMP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:EUGENE
Last Name:CRUZAN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 SW 139TH ST APT 147
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1111
Mailing Address - Country:US
Mailing Address - Phone:206-380-9231
Mailing Address - Fax:
Practice Address - Street 1:14700 NE 8TH ST STE 115
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-4115
Practice Address - Country:US
Practice Address - Phone:425-644-8386
Practice Address - Fax:425-604-2560
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022315225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0207353OtherL&I I.D. NUMBER
WA8942567OtherCRIME VICTIMS COMP. PROG.