Provider Demographics
NPI:1942583513
Name:CALLUM, JASON CHARLES
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:CHARLES
Last Name:CALLUM
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 1:3232 BRAYTON MIST DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6518
Mailing Address - Country:US
Mailing Address - Phone:702-235-8376
Mailing Address - Fax:
Practice Address - Street 1:4100 N. MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081
Practice Address - Country:US
Practice Address - Phone:702-552-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty