Provider Demographics
NPI:1598267767
Name:ITZ, JASON SCOTT (CI)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:ITZ
Suffix:
Gender:M
Credentials:CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 GLASCOW ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1406
Mailing Address - Country:US
Mailing Address - Phone:361-576-3385
Mailing Address - Fax:
Practice Address - Street 1:506 GLASCOW ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1406
Practice Address - Country:US
Practice Address - Phone:361-576-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38208101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)