Provider Demographics
NPI:1922304948
Name:LAKE, JASON BENNETT (LCSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BENNETT
Last Name:LAKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LOGGER CT STE G103
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-8512
Mailing Address - Country:US
Mailing Address - Phone:919-538-5511
Mailing Address - Fax:
Practice Address - Street 1:1100 LOGGER CT
Practice Address - Street 2:G-103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-8525
Practice Address - Country:US
Practice Address - Phone:919-538-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC006990OtherSTATE LICENSE