Provider Demographics
NPI:1225373665
Name:WEASE, JERRY (LCAS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WEASE
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 CALLAHAN KOON RD
Mailing Address - Street 2:
Mailing Address - City:SPINDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28160-2207
Mailing Address - Country:US
Mailing Address - Phone:828-288-8773
Mailing Address - Fax:828-288-9577
Practice Address - Street 1:271 CALLAHAN KOON RD
Practice Address - Street 2:
Practice Address - City:SPINDALE
Practice Address - State:NC
Practice Address - Zip Code:28160-2207
Practice Address - Country:US
Practice Address - Phone:828-288-8773
Practice Address - Fax:828-288-9577
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2456101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)