Healthcare Provider Details

I. General information

NPI: 1962276790
Provider Name (Legal Business Name): JASON JARVIS LPC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 11/13/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

PO BOX 309
SIREN WI
54872-0309
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4402
  • Fax:
Mailing address:
  • Phone: 715-349-7069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7662
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: