Provider Demographics
NPI:1073892972
Name:LEVINE, JASON C (PHD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:LEVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 KIMBALL CRK S
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-8206
Mailing Address - Country:US
Mailing Address - Phone:419-290-8489
Mailing Address - Fax:
Practice Address - Street 1:2801 W BANCROFT ST # 948
Practice Address - Street 2:UNIVERSITY OF TOLEDO - DEPT. OF PSYCHOLOGY
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3328
Practice Address - Country:US
Practice Address - Phone:419-530-2761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
OHOH6958103TC0700X
OH6958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0217029Medicaid