Healthcare Provider Details

I. General information

NPI: 1740528702
Provider Name (Legal Business Name): VAJRA PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2013
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 N STATE ST SUITE J
NORTH VERNON IN
47265-1044
US

IV. Provider business mailing address

753 N STATE ST SUITE J
NORTH VERNON IN
47265-1044
US

V. Phone/Fax

Practice location:
  • Phone: 812-346-7744
  • Fax: 812-346-3815
Mailing address:
  • Phone: 812-346-7744
  • Fax: 812-346-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20042015A
License Number StateIN

VIII. Authorized Official

Name: DR. JASON HOLLAND
Title or Position: OWNER
Credential: PHD
Phone: 812-498-3470