Provider Demographics
NPI:1942970587
Name:WALLER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WALLER
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 1:4415 LOOP 322
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-8056
Mailing Address - Country:US
Mailing Address - Phone:325-386-3466
Mailing Address - Fax:
Practice Address - Street 1:4415 LOOP 322
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-8056
Practice Address - Country:US
Practice Address - Phone:325-386-3466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional