Provider Demographics
NPI:1174845788
Name:LANDRY, JASON MICHAEL (LAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:LANDRY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 SW 119TH PL
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98146-2513
Mailing Address - Country:US
Mailing Address - Phone:206-612-5181
Mailing Address - Fax:
Practice Address - Street 1:3417 FREMONT AVE N
Practice Address - Street 2:STE 305
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3411
Practice Address - Country:US
Practice Address - Phone:206-621-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60135383171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist