1225189590 NPI number — JASE EVAERET BRENDEN L.AC., LMT

Table of content: JASE EVAERET BRENDEN L.AC., LMT (NPI 1225189590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225189590 NPI number — JASE EVAERET BRENDEN L.AC., LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENDEN
Provider First Name:
JASE
Provider Middle Name:
EVAERET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.AC., LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225189590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4838 NE SANDY BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97213-2090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-287-1510
Provider Business Mailing Address Fax Number:
503-287-1505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4838 NE SANDY BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-2090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-287-1510
Provider Business Practice Location Address Fax Number:
503-287-1505
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC00486 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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