Provider Demographics
NPI:1497088520
Name:SPANN, JASON ELIJAH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ELIJAH
Last Name:SPANN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06601-0084
Mailing Address - Country:US
Mailing Address - Phone:203-996-2661
Mailing Address - Fax:203-336-6525
Practice Address - Street 1:1057 BROAD ST FL 3
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4219
Practice Address - Country:US
Practice Address - Phone:203-996-2661
Practice Address - Fax:203-336-6525
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT71061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical