Provider Demographics
NPI:1689962060
Name:WILDE, JASON EDWARD (LPC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:EDWARD
Last Name:WILDE
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 1:1360 E 1450 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1611
Mailing Address - Country:US
Mailing Address - Phone:801-773-0712
Mailing Address - Fax:
Practice Address - Street 1:1360 E 1450 S
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1611
Practice Address - Country:US
Practice Address - Phone:801-773-0712
Practice Address - Fax:801-774-8267
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5638133-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid
UT260022408OtherRAILROAD MEDICARE
UT260022408OtherRAILROAD MEDICARE