Provider Demographics
NPI:1538536016
Name:PRINCE, JASON (BCSI, LMP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:BCSI, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6112 S 1550 E STE 203
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-5010
Mailing Address - Country:US
Mailing Address - Phone:801-888-0103
Mailing Address - Fax:801-475-1795
Practice Address - Street 1:6112 S 1550 E STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5010
Practice Address - Country:US
Practice Address - Phone:801-897-8710
Practice Address - Fax:801-475-1795
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT366375-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist