Healthcare Provider Details

I. General information

NPI: 1699053512
Provider Name (Legal Business Name): JASON STREET LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 BROOKHAVEN RD
FRANKLIN KY
42134-2743
US

IV. Provider business mailing address

380 SUWANNEE TRAIL ST
BOWLING GREEN KY
42103-7956
US

V. Phone/Fax

Practice location:
  • Phone: 270-901-5000
  • Fax: 270-586-8828
Mailing address:
  • Phone: 270-901-5000
  • Fax: 270-842-5268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1239
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: