Provider Demographics
NPI:1205914173
Name:MATHERS, JASON FORREST (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:FORREST
Last Name:MATHERS
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CLARKSON EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2176
Mailing Address - Country:US
Mailing Address - Phone:636-256-0600
Mailing Address - Fax:636-256-0626
Practice Address - Street 1:119 CLARKSON EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2176
Practice Address - Country:US
Practice Address - Phone:636-256-0600
Practice Address - Fax:636-256-0626
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014823101YM0800X
MO2006036655103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist