Healthcare Provider Details

I. General information

NPI: 1619458734
Provider Name (Legal Business Name): JASON FRANCIS LAACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 JOHN RINGLING BLVD FL 34236
SARASOTA FL
34236-1542
US

IV. Provider business mailing address

99 ROTONDA CIR
ROTONDA WEST FL
33947-2241
US

V. Phone/Fax

Practice location:
  • Phone: 941-365-2600
  • Fax:
Mailing address:
  • Phone: 223-834-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number214627
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number15343
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: