=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871388595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON ADAM BYRD 390200000X STUDENT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2025
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 LIMIT ST
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-682-5118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1535 W 15TH ST FL 3
-----------------------------------------------------
City | LAWRENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66045-7608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-864-4720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 14285
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------