Provider Demographics
NPI:1174819320
Name:SUTTON, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SUTTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 LANGLEY RD N STE A
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-6531
Mailing Address - Country:US
Mailing Address - Phone:410-222-6785
Mailing Address - Fax:
Practice Address - Street 1:122 LANGLEY RD N STE A
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-6531
Practice Address - Country:US
Practice Address - Phone:410-222-6785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health