Provider Demographics
NPI:1306226600
Name:BELCOURT, JASON TYLER
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:TYLER
Last Name:BELCOURT
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 1:290 NEW RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:HARDEEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29927-4406
Mailing Address - Country:US
Mailing Address - Phone:203-379-7615
Mailing Address - Fax:
Practice Address - Street 1:883 PADDOCK AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7044
Practice Address - Country:US
Practice Address - Phone:860-852-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6123101YP2500X, 101Y00000X
CT2651101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional