Provider Demographics
NPI:1033521687
Name:NIETZKE, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:NIETZKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 STEPHENSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5829
Mailing Address - Country:US
Mailing Address - Phone:912-200-3195
Mailing Address - Fax:
Practice Address - Street 1:132 STEPHENSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5829
Practice Address - Country:US
Practice Address - Phone:912-200-3195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007803101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional