Provider Demographics
NPI:1881926889
Name:LEE, JASON THOMAS (LAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:LEE
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 1:1011 41ST AVE NE APT 204
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3168
Mailing Address - Country:US
Mailing Address - Phone:612-747-2430
Mailing Address - Fax:
Practice Address - Street 1:1011 41ST AVE NE APT 204
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-3168
Practice Address - Country:US
Practice Address - Phone:612-747-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
MN1786171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist