Provider Demographics
NPI:1265204739
Name:LASC, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LASC
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 1:1911 S NATIONAL AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2256
Mailing Address - Country:US
Mailing Address - Phone:417-299-4080
Mailing Address - Fax:
Practice Address - Street 1:1911 S NATIONAL AVE STE 306
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2256
Practice Address - Country:US
Practice Address - Phone:417-299-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019032649225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist