Provider Demographics
NPI:1871888529
Name:LIEM, JONATHAN JASON (CMT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:JASON
Last Name:LIEM
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 S BUSHNELL AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3926
Mailing Address - Country:US
Mailing Address - Phone:213-503-5338
Mailing Address - Fax:
Practice Address - Street 1:56 E DUARTE RD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3511
Practice Address - Country:US
Practice Address - Phone:626-447-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist