Provider Demographics
NPI:1417357393
Name:BEYER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BEYER
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 1:1845 FAIRMOUNT ST
Mailing Address - Street 2:BOX 91
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260-0091
Mailing Address - Country:US
Mailing Address - Phone:316-978-3440
Mailing Address - Fax:
Practice Address - Street 1:1845 FAIRMOUNT ST
Practice Address - Street 2:BOX 91
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67260-0091
Practice Address - Country:US
Practice Address - Phone:316-978-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical