Provider Demographics
NPI:1144562604
Name:WALTER, JASON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:WALTER
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 1:177 PRINCE STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2936
Mailing Address - Country:US
Mailing Address - Phone:312-296-9405
Mailing Address - Fax:
Practice Address - Street 1:177 PRINCE STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2936
Practice Address - Country:US
Practice Address - Phone:917-243-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0846191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical