Provider Demographics
NPI:1912363375
Name:BASTIAN, JAY ALAN (LSW)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ALAN
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 WOODHURST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-3134
Mailing Address - Country:US
Mailing Address - Phone:260-418-9653
Mailing Address - Fax:
Practice Address - Street 1:5004 WOODHURST BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3134
Practice Address - Country:US
Practice Address - Phone:260-418-9653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007337A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker