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General NPI Number Information
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NPI Number | 1679435028
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Entity Type | Individual
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Provider Name | JASON CLARK LAGE BCTMB
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Gender | Male
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Dates
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Enumeration Date | 11/24/2025
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Last Update Date | 11/24/2025
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Provider Practice Location Address
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Address Line | 2700 1ST ST N STE 101
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City | SAINT CLOUD
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State | MN
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Zip | 56303-4202
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Country | US
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Telephone | 605-786-5327
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Fax |
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Provider Business Mailing Address
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Address Line | 10720 W LAKE RD
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City | RICE
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State | MN
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Zip | 56367-8668
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Country | US
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Telephone | 605-786-5327
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | HMGT24-0060
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 173C00000X
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Taxonomy Name | Reflexologist
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License Number | HMGT24-0060
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License Number State | MN
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