MEDICARE: JASON WYATT, LPCC, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336718287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASON WYATT, LPCC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 375
Second Line	:
City	:	FAIRACRES
State	:	NM
Zip	:	88033-0375
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 N VALLEY DR STE 12
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-5121
Country	:	US
Telephone Number	:	575-642-5544
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	JASON WYATT
Credential	:
Telephone Number	:	575-642-5544

Provider Enumeration Date	:	06/23/2021
Last Update Date	:	09/07/2021

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