Provider Demographics
NPI:1568806396
Name:LEISTAD, JASON ARNIE (LAC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ARNIE
Last Name:LEISTAD
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:PO BOX 3103
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97707-0103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56881 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SUNRIVER
Practice Address - State:OR
Practice Address - Zip Code:97707-2120
Practice Address - Country:US
Practice Address - Phone:541-593-8535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR160583171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist