Provider Demographics
NPI:1013676055
Name:JASON BRENT FEDELI PROFESSIONAL COUNSELING LLC
Entity type:Organization
Organization Name:JASON BRENT FEDELI PROFESSIONAL COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:B
Authorized Official - Last Name:FEDELI
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC-S
Authorized Official - Phone:907-315-1955
Mailing Address - Street 1:9330 VANGUARD DR STE 202
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-5393
Mailing Address - Country:US
Mailing Address - Phone:907-202-2527
Mailing Address - Fax:
Practice Address - Street 1:9330 VANGUARD DR STE 202
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-5393
Practice Address - Country:US
Practice Address - Phone:907-202-2527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1013676055OtherNPI II
AK1724757Medicaid
AK1724759Medicaid