MEDICARE: JASON M MCCOY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	007307	IA
2	1041C0700X	Clinical Social Worker	55930	TX

General Provider Information

NPI Number	:	1215164835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON M MCCOY LCSW

Provider Business Mailing Address
First Line	:	3629 WESTERN CENTER BLVD
Second Line	:	STE. 211
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1939
Country	:	US
Telephone Number	:	469-999-3208
Fax Number	:

Provider Business Practice Location Address
First Line	:	3629 WESTERN CENTER BLVD
Second Line	:	STE. 211
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1939
Country	:	US
Telephone Number	:	817-232-9400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2009
Last Update Date	:	12/08/2011

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