Provider Demographics
NPI:1174384473
Name:GARDNER, JA'SON C
Entity type:Individual
Prefix:
First Name:JA'SON
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7639 DAY ST APT 127
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-2596
Mailing Address - Country:US
Mailing Address - Phone:661-400-7712
Mailing Address - Fax:
Practice Address - Street 1:7639 DAY ST APT 127
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-2596
Practice Address - Country:US
Practice Address - Phone:661-400-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95529225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist