MEDICARE: JASON SCULLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	839445	CA

General Provider Information

NPI Number	:	1073111886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON SCULLY

Provider Business Mailing Address
First Line	:	871 SUNSET CT
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4145
Country	:	US
Telephone Number	:	707-971-6648
Fax Number	:

Provider Business Practice Location Address
First Line	:	871 SUNSET CT
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4145
Country	:	US
Telephone Number	:	707-971-6649
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	10/14/2020

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Directions to “ JASON SCULLY ” Practice Location

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