Provider Demographics
NPI:1093992919
Name:ERICKSON, JASON P (LCP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0467
Mailing Address - Country:US
Mailing Address - Phone:316-634-4700
Mailing Address - Fax:316-634-4770
Practice Address - Street 1:9333 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2927
Practice Address - Country:US
Practice Address - Phone:316-634-4700
Practice Address - Fax:316-634-4770
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1149103TC0700X
KS1480103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical