Provider Demographics
NPI:1689327363
Name:CLIFFGARD, JASON A (LPC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:CLIFFGARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E HOLMES ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-4200
Mailing Address - Country:US
Mailing Address - Phone:262-203-4630
Mailing Address - Fax:
Practice Address - Street 1:1173 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1672
Practice Address - Country:US
Practice Address - Phone:262-458-2525
Practice Address - Fax:262-458-2680
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6695-125101YM0800X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health