Provider Demographics
NPI:1780867630
Name:THAYER, JASON (LCSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:THAYER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-6155
Mailing Address - Country:US
Mailing Address - Phone:606-679-6995
Mailing Address - Fax:606-451-9465
Practice Address - Street 1:149 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-6155
Practice Address - Country:US
Practice Address - Phone:606-679-6995
Practice Address - Fax:606-451-9465
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400037013Medicare PIN