Provider Demographics
NPI:1689914962
Name:ANDERSON, JASON DREW (MSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:DREW
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28042-0192
Mailing Address - Country:US
Mailing Address - Phone:704-842-6476
Mailing Address - Fax:
Practice Address - Street 1:2505 COURT DR # B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-842-6476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0078721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical