Provider Demographics
NPI:1740516731
Name:ANDERSEN, JASON A (PSYD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:A
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:120 E TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3302
Mailing Address - Country:US
Mailing Address - Phone:404-668-3766
Mailing Address - Fax:
Practice Address - Street 1:120 E TRINITY PL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3302
Practice Address - Country:US
Practice Address - Phone:404-668-3766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3325103TC0700X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent