Healthcare Provider Details

I. General information

NPI: 1114308012
Provider Name (Legal Business Name): JOHN MEJASIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 N ELM ST
CANBY OR
97013-3519
US

IV. Provider business mailing address

113 N ELM ST
CANBY OR
97013-3519
US

V. Phone/Fax

Practice location:
  • Phone: 503-263-8903
  • Fax: 503-266-8632
Mailing address:
  • Phone: 503-263-8903
  • Fax: 503-266-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number341015
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: