Provider Demographics
NPI:1407088503
Name:COLE, JASON SCOTT (LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:COLE
Suffix:
Gender:M
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 S MARATHON LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-6178
Mailing Address - Country:US
Mailing Address - Phone:630-605-6019
Mailing Address - Fax:630-551-2213
Practice Address - Street 1:705 N SPARKLE CT
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7942
Practice Address - Country:US
Practice Address - Phone:630-913-7045
Practice Address - Fax:630-551-2213
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-22
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004934101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health