Provider Demographics
NPI:1265030449
Name:LEVI, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LEVI
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 1:217 LELAND DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4761
Mailing Address - Country:US
Mailing Address - Phone:336-749-4213
Mailing Address - Fax:
Practice Address - Street 1:217 LELAND DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4761
Practice Address - Country:US
Practice Address - Phone:336-749-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5559103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool