Provider Demographics
NPI:1619161676
Name:BLACK, JASON (LMFT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 ALBERTA ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1507
Mailing Address - Country:US
Mailing Address - Phone:203-400-2407
Mailing Address - Fax:
Practice Address - Street 1:487 CHURCH HILL RD FL 2
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3838
Practice Address - Country:US
Practice Address - Phone:203-400-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1325106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008034442Medicaid