=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811492994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON J WHEELER MS/CAGS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 03/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | KING GEORGE HIGH SCHOOL 10100 FOXES WAY
-----------------------------------------------------
City | KING GEORGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-775-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1239
-----------------------------------------------------
City | KING GEORGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22485-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | PGP-0673762
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------