=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285874040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON SELK M.ED, LPC, NCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2009
-----------------------------------------------------
Last Update Date | 03/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 S MERAMEC AVE SUITE 829
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-341-9496
-----------------------------------------------------
Fax | 636-256-4518
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 S MERAMEC AVE SUITE 829
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-341-9496
-----------------------------------------------------
Fax | 636-256-4518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 2000159344
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------