Provider Demographics
NPI:1669299624
Name:CONOVER, JASON B (LCAT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:B
Last Name:CONOVER
Suffix:
Gender:M
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 WALLACE AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2480
Mailing Address - Country:US
Mailing Address - Phone:347-661-5342
Mailing Address - Fax:
Practice Address - Street 1:2105 WALLACE AVE APT 3E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2480
Practice Address - Country:US
Practice Address - Phone:347-661-5342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001380101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist