Healthcare Provider Details

I. General information

NPI: 1902615313
Provider Name (Legal Business Name): ELIJAHBEN JASSO LCPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2025
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 E 5TH ST
LOVELL WY
82431-1902
US

IV. Provider business mailing address

52 E 5TH ST
LOVELL WY
82431-1902
US

V. Phone/Fax

Practice location:
  • Phone: 307-272-7042
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-89881
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: