Provider Demographics
NPI:1205348281
Name:BIRD, JASON (PHD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:BIRD
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 1:30 HOBCAW DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4416
Mailing Address - Country:US
Mailing Address - Phone:864-905-8195
Mailing Address - Fax:
Practice Address - Street 1:15720 BRIXHAM HILL AVENUE
Practice Address - Street 2:150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-970-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical