Provider Demographics
NPI:1841711538
Name:LICAUSI, JASON P (LMFT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:P
Last Name:LICAUSI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 CANOPY CIR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34120
Mailing Address - Country:US
Mailing Address - Phone:239-826-4870
Mailing Address - Fax:
Practice Address - Street 1:3049 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7041
Practice Address - Country:US
Practice Address - Phone:239-826-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT2296101YM0800X
FLMT3395101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty