Provider Demographics
NPI:1851609812
Name:THOMAS, JASON (LEP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12211 LAUREL TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6210 WILSHIRE BLVD
Practice Address - Street 2:207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5105
Practice Address - Country:US
Practice Address - Phone:323-702-2706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3167103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool