Provider Demographics
NPI:1831635952
Name:PARKS, JASON LIAM
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LIAM
Last Name:PARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 GLEN VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9436
Mailing Address - Country:US
Mailing Address - Phone:240-210-0955
Mailing Address - Fax:
Practice Address - Street 1:7175 COLUMBIA GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2534
Practice Address - Country:US
Practice Address - Phone:888-344-5977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00000000000000000000106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician