Provider Demographics
NPI:1700019254
Name:RODERICK, JASON G (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:RODERICK
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-1652
Mailing Address - Country:US
Mailing Address - Phone:401-439-4159
Mailing Address - Fax:
Practice Address - Street 1:35 S ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5206
Practice Address - Country:US
Practice Address - Phone:401-439-4159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2601849OtherDMV