Provider Demographics
NPI:1558437194
Name:GRANT, ROBERT JASON (EDD LPC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JASON
Last Name:GRANT
Suffix:
Gender:M
Credentials:EDD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 E HWY CC
Mailing Address - Street 2:SUITE A105
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714
Mailing Address - Country:US
Mailing Address - Phone:417-725-8810
Mailing Address - Fax:417-725-6206
Practice Address - Street 1:380 E HWY CC
Practice Address - Street 2:SUITE A105
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714
Practice Address - Country:US
Practice Address - Phone:417-725-8810
Practice Address - Fax:417-725-6206
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001008080101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional