Healthcare Provider Details

I. General information

NPI: 1740516731
Provider Name (Legal Business Name): JASON A ANDERSEN PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANDY ANDERSEN PSY.D

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E TRINITY PL
DECATUR GA
30030-3302
US

IV. Provider business mailing address

120 E TRINITY PL
DECATUR GA
30030-3302
US

V. Phone/Fax

Practice location:
  • Phone: 404-668-3766
  • Fax:
Mailing address:
  • Phone: 404-668-3766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3325
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3325
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number3325
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: