Basic Information
| Provider Information | |||||||||
| NPI: | 1851818215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACSON | ||||||||
| FirstName: | JEREMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 THE WOODS DR APT 1222 | ||||||||
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| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951363855 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
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| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088855000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2017 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 291749 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.