Healthcare Provider Details

I. General information

NPI: 1487084182
Provider Name (Legal Business Name): JONATHAN GHAZAL MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 WATER ST NE APT 76
SALEM OR
97301-0792
US

IV. Provider business mailing address

1663 WATER ST NE APT 76
SALEM OR
97301-0792
US

V. Phone/Fax

Practice location:
  • Phone: 503-339-5938
  • Fax:
Mailing address:
  • Phone: 503-339-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-10154552
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT7016
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: