Provider Demographics
NPI:1295158970
Name:DOUGHERTY, JASON JAMES (LMSW)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:JAMES
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10339W STATE HIGHWAY M149
Mailing Address - Street 2:
Mailing Address - City:COOKS
Mailing Address - State:MI
Mailing Address - Zip Code:49817-9768
Mailing Address - Country:US
Mailing Address - Phone:906-286-2016
Mailing Address - Fax:
Practice Address - Street 1:813 E LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1683
Practice Address - Country:US
Practice Address - Phone:906-341-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010934051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical