Healthcare Provider Details

I. General information

NPI: 1114706793
Provider Name (Legal Business Name): MR. JASON PLICHTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

1 CONCORDIA DR
CARBONDALE IL
62902-8025
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone: 847-902-7933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: