Healthcare Provider Details

I. General information

NPI: 1114478179
Provider Name (Legal Business Name): JASON ALLEN COUNTS LISW-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S HENRY ST
DELAWARE OH
43015-2978
US

IV. Provider business mailing address

388 DAMASCUS RD
MARYSVILLE OH
43040-5535
US

V. Phone/Fax

Practice location:
  • Phone: 740-369-4482
  • Fax:
Mailing address:
  • Phone: 937-578-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2304574-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: