Healthcare Provider Details

I. General information

NPI: 1801152608
Provider Name (Legal Business Name): JASON A RUIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 UNION ST SUITE 557
LAWRENCE MA
01840-1866
US

IV. Provider business mailing address

42 CRESTWOOD CIR
LAWRENCE MA
01843-1951
US

V. Phone/Fax

Practice location:
  • Phone: 978-651-2551
  • Fax:
Mailing address:
  • Phone: 978-651-2551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberS12281707
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberS12281707
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS12281707
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: