Provider Demographics
NPI:1821852484
Name:DAVIS, JASON WAYNE (MIP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 TANGER BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-3597
Mailing Address - Country:US
Mailing Address - Phone:125-589-0168
Mailing Address - Fax:812-522-0291
Practice Address - Street 1:357 TANGER BLVD STE 215
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3597
Practice Address - Country:US
Practice Address - Phone:812-558-9016
Practice Address - Fax:812-522-0291
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)