Healthcare Provider Details

I. General information

NPI: 1962975771
Provider Name (Legal Business Name): JASON VINCENT LACSAMANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LINK DR
ROCKLEIGH NJ
07647-2504
US

IV. Provider business mailing address

16 EMERALD ST
HACKENSACK NJ
07601-6101
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00244300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: