Provider Demographics
NPI:1245017771
Name:MIZAK, JASON (RBT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MIZAK
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 NE HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-9209
Mailing Address - Country:US
Mailing Address - Phone:303-880-3745
Mailing Address - Fax:813-441-8362
Practice Address - Street 1:3715 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9209
Practice Address - Country:US
Practice Address - Phone:303-880-3745
Practice Address - Fax:813-441-8362
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRBT-23-280471106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty