MEDICARE: JASON W WALLER MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	C.2305477	OH

General Provider Information

NPI Number	:	1093592719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON W WALLER MA, LPC

Provider Business Mailing Address
First Line	:	3127 QUINBY DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-7734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3127 QUINBY DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-7734
Country	:	US
Telephone Number	:	765-586-6894
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2023
Last Update Date	:	09/14/2023

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