Provider Demographics
NPI:1619458734
Name:LAACK, JASON FRANCIS
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:FRANCIS
Last Name:LAACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 ROTONDA CIR
Mailing Address - Street 2:
Mailing Address - City:ROTONDA WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33947-2241
Mailing Address - Country:US
Mailing Address - Phone:223-834-1140
Mailing Address - Fax:
Practice Address - Street 1:700 JOHN RINGLING BLVD FL 34236
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-1542
Practice Address - Country:US
Practice Address - Phone:941-365-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214627224Z00000X
FL15343224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant