Provider Demographics
NPI:1063909489
Name:PYEATT, JASON (LAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PYEATT
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 1:565 PROSPECT PL APT 1F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4273
Mailing Address - Country:US
Mailing Address - Phone:917-301-8188
Mailing Address - Fax:
Practice Address - Street 1:565 PROSPECT PL APT 1F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4273
Practice Address - Country:US
Practice Address - Phone:917-301-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006237171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist