Provider Demographics
NPI:1942900238
Name:EDWARDS, JASON L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 FORUM BLVD APT 115
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6803
Mailing Address - Country:US
Mailing Address - Phone:617-733-2814
Mailing Address - Fax:
Practice Address - Street 1:3705 FORUM BLVD APT 115
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6803
Practice Address - Country:US
Practice Address - Phone:617-733-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022012889103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling