Provider Demographics
NPI:1457491334
Name:SMALLWOOD, JASON R (LPCA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:063-298-5886
Mailing Address - Fax:
Practice Address - Street 1:300 FOXGLOVE DR
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9769
Practice Address - Country:US
Practice Address - Phone:866-233-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY3311Medicare ID - Type UnspecifiedMEDICARE