Provider Demographics
NPI:1689024796
Name:HART, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:HART
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 1:5520 SW MACADAM AVE
Mailing Address - Street 2:230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3768
Mailing Address - Country:US
Mailing Address - Phone:503-243-3443
Mailing Address - Fax:
Practice Address - Street 1:5520 SW MACADAM AVE
Practice Address - Street 2:230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3768
Practice Address - Country:US
Practice Address - Phone:503-243-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3831225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist