Provider Demographics
NPI:1750771473
Name:PETTIT, JASON R (LCDC, LPO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:PETTIT
Suffix:
Gender:M
Credentials:LCDC, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 W PARNELL ST
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-1123
Mailing Address - Country:US
Mailing Address - Phone:903-816-2405
Mailing Address - Fax:
Practice Address - Street 1:1739 W PARNELL ST
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1123
Practice Address - Country:US
Practice Address - Phone:903-816-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health