Provider Demographics
NPI:1164738746
Name:ELLIOTT, JASON (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N HARRISON ST
Mailing Address - Street 2:ATTN: ANNE LAWSON
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3163
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-268-2377
Practice Address - Street 1:2100 GOSHEN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-1493
Practice Address - Country:US
Practice Address - Phone:260-471-3500
Practice Address - Fax:260-471-4263
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002433A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health