Provider Demographics
NPI:1285872549
Name:RICHARD, JASON (LAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:RICHARD
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 1:1205 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-4566
Mailing Address - Country:US
Mailing Address - Phone:507-434-3516
Mailing Address - Fax:
Practice Address - Street 1:115 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-3305
Practice Address - Country:US
Practice Address - Phone:507-434-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-25
Last Update Date:2009-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1193171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist