Provider Demographics
NPI:1700421120
Name:LACANLALE, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LACANLALE
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 1:6759 SIERRA CT
Mailing Address - Street 2:STE A
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2657
Mailing Address - Country:US
Mailing Address - Phone:925-803-0530
Mailing Address - Fax:
Practice Address - Street 1:1895 MOWRY AVE STE 115
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1766
Practice Address - Country:US
Practice Address - Phone:510-790-3213
Practice Address - Fax:510-790-3337
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT297570OtherLICENSE