Provider Demographics
NPI:1699955435
Name:LUIS, JAYSON ADAM (LAC, DIPL OM)
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:ADAM
Last Name:LUIS
Suffix:
Gender:M
Credentials:LAC, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 GERARD AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-8829
Mailing Address - Country:US
Mailing Address - Phone:718-772-5987
Mailing Address - Fax:
Practice Address - Street 1:1114 GERARD AVE APT 22
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-8829
Practice Address - Country:US
Practice Address - Phone:718-772-5987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25 003651171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist