Healthcare Provider Details

I. General information

NPI: 1386923480
Provider Name (Legal Business Name): JASON ALEXANDER CHONG PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 COOMBS FARM DRIVE SUITE 202
MORGANTOWN WV
26508
US

IV. Provider business mailing address

1208 CHASE ST
MORGANTOWN WV
26508-6840
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-0504
  • Fax: 304-554-0505
Mailing address:
  • Phone: 503-724-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1024
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1024
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: