Provider Demographics
NPI:1518561018
Name:HENRY, JASON PATRICK (RBT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:PATRICK
Last Name:HENRY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2692 CHRISTOPHER TER
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8902
Mailing Address - Country:US
Mailing Address - Phone:719-686-4902
Mailing Address - Fax:
Practice Address - Street 1:2760 FIELDSTONE RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3100
Practice Address - Country:US
Practice Address - Phone:719-203-6903
Practice Address - Fax:719-203-6904
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-146073106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician