Provider Demographics
NPI:1790238079
Name:EVELETH, JASON (MS ED, LMHC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:EVELETH
Suffix:
Gender:M
Credentials:MS ED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3110
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:713 TROY SCHENECTADY RD STE 224
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2490
Practice Address - Country:US
Practice Address - Phone:518-785-5881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007336-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health