Provider Demographics
NPI:1063940435
Name:BUKICH, JASON VINCENT (MSAOM LAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:VINCENT
Last Name:BUKICH
Suffix:
Gender:M
Credentials:MSAOM LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24586 VIA DEL ORO
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7605
Mailing Address - Country:US
Mailing Address - Phone:949-735-9981
Mailing Address - Fax:
Practice Address - Street 1:24586 VIA DEL ORO
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7605
Practice Address - Country:US
Practice Address - Phone:949-735-9981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17503171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist