Provider Demographics
NPI:1972623858
Name:SU, JASON (LAC)
Entity type:Individual
Prefix:PROF
First Name:JASON
Middle Name:
Last Name:SU
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 1:1364 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4620
Mailing Address - Country:US
Mailing Address - Phone:510-523-2870
Mailing Address - Fax:
Practice Address - Street 1:433 CALLAN AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4643
Practice Address - Country:US
Practice Address - Phone:510-483-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3487171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist