Provider Demographics
NPI:1720444730
Name:BAILEY, JASON T
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
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 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-4000
Mailing Address - Fax:937-641-4500
Practice Address - Street 1:1425 N FAIRFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2674
Practice Address - Country:US
Practice Address - Phone:937-641-5772
Practice Address - Fax:937-641-4668
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.23049911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0039579Medicaid