Provider Demographics
NPI:1740838408
Name:LEAVERTON, JASON (MA, NCC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LEAVERTON
Suffix:
Gender:M
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:TN
Mailing Address - Zip Code:37142-2142
Mailing Address - Country:US
Mailing Address - Phone:615-239-4849
Mailing Address - Fax:
Practice Address - Street 1:203 HARNETT CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-1966
Practice Address - Country:US
Practice Address - Phone:931-614-7397
Practice Address - Fax:931-443-0079
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN5109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health