Provider Demographics
NPI:1083963771
Name:PEREZ, JASON M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:M
Last Name:PEREZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 CHAMBERLAIN HWY
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1921
Mailing Address - Country:US
Mailing Address - Phone:860-893-0040
Mailing Address - Fax:860-893-0046
Practice Address - Street 1:26 CHAMBERLAIN HWY
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1921
Practice Address - Country:US
Practice Address - Phone:860-893-0040
Practice Address - Fax:860-893-0046
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
390200000X
CT0097691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program