Provider Demographics
NPI:1356870927
Name:DAVIS, JASON THOMAS (MA, LPC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 CRAWFORD AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4959
Mailing Address - Country:US
Mailing Address - Phone:224-688-2277
Mailing Address - Fax:
Practice Address - Street 1:2530 CRAWFORD AVE STE 208
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4959
Practice Address - Country:US
Practice Address - Phone:224-688-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional