Provider Demographics
NPI:1568053700
Name:LIVERMORE, JASEN J (PPC)
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:J
Last Name:LIVERMORE
Suffix:
Gender:M
Credentials:PPC
Other - Prefix:
Other - First Name:JASEN
Other - Middle Name:J
Other - Last Name:LIVERMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:121 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2634
Mailing Address - Country:US
Mailing Address - Phone:307-864-3138
Mailing Address - Fax:307-568-2503
Practice Address - Street 1:121 S 4TH ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2634
Practice Address - Country:US
Practice Address - Phone:307-864-3138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-2245101YP2500X
WYCSW-330101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health