Provider Demographics
NPI:1205536513
Name:ROBERSHAW, JASON KYLE (MA, LCPC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:KYLE
Last Name:ROBERSHAW
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 US HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3766
Mailing Address - Country:US
Mailing Address - Phone:618-841-4459
Mailing Address - Fax:
Practice Address - Street 1:1412 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3766
Practice Address - Country:US
Practice Address - Phone:618-841-4459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015046101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional