Individual
MR. JASON RICHARD COSTELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LAC
Contact information
Practice address
909 SW 12TH AVE., 111, PORTLAND, OR 97205-2070
(310) 993-9429
Mailing address
909 SW 12TH AVE., 111, PORTLAND, OR 97205-2070
(310) 993-9429
Taxonomy
Speciality
Code
Description
License number
State
171100000X
Acupuncturist
Primary
AC00987
OR
Other
Enumeration date
02/09/2007
Last updated
07/08/2007
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