Provider Demographics
NPI:1265804652
Name:DERICO, JASON (ND)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DERICO
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4757 SW 141ST AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3750
Mailing Address - Country:US
Mailing Address - Phone:435-764-7725
Mailing Address - Fax:
Practice Address - Street 1:4757 SW 141ST AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3750
Practice Address - Country:US
Practice Address - Phone:503-610-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3026175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath