Provider Demographics
NPI:1326583477
Name:VASTARDIS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:VASTARDIS
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 1:680 AMERICAN AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4023
Mailing Address - Country:US
Mailing Address - Phone:610-644-6464
Mailing Address - Fax:610-981-6078
Practice Address - Street 1:107 CHESLEY DR
Practice Address - Street 2:#5
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1760
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:610-981-6078
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009008101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional