Provider Demographics
NPI:1407199656
Name:FEDELI, JASON BRENT (MA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:BRENT
Last Name:FEDELI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 N GREENTREE ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-4609
Mailing Address - Country:US
Mailing Address - Phone:907-315-5755
Mailing Address - Fax:
Practice Address - Street 1:3521 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-1111
Practice Address - Country:US
Practice Address - Phone:907-868-1105
Practice Address - Fax:844-540-0938
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AK119538101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK119538OtherSTATE OF ALASKA LPC LICENSE