Provider Demographics
NPI:1558980763
Name:FERRELL, JASON L (LADAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:FERRELL
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 JUNIPER RD
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6636
Mailing Address - Country:US
Mailing Address - Phone:817-243-6468
Mailing Address - Fax:
Practice Address - Street 1:195 JUNIPER RD
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6636
Practice Address - Country:US
Practice Address - Phone:817-243-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13580101YA0400X
NMCAD0208871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)