Provider Demographics
NPI:1407997679
Name:COSTELLO, JASON RICHARD (LAC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:RICHARD
Last Name:COSTELLO
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 1:909 SW 12TH AVE.
Mailing Address - Street 2:111
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2070
Mailing Address - Country:US
Mailing Address - Phone:310-993-9429
Mailing Address - Fax:
Practice Address - Street 1:909 SW 12TH AVE.
Practice Address - Street 2:111
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2070
Practice Address - Country:US
Practice Address - Phone:310-993-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00987171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist