Healthcare Provider Details

I. General information

NPI: 1114619004
Provider Name (Legal Business Name): JAN BLAS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20215 POWERS RD
BEND OR
97702-3705
US

IV. Provider business mailing address

20215 POWERS RD
BEND OR
97702-3705
US

V. Phone/Fax

Practice location:
  • Phone: 458-256-8176
  • Fax:
Mailing address:
  • Phone: 458-256-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number65215
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: