Provider Demographics
NPI:1932400330
Name:BURDGE, JASON MICHAEL (CCDC, CBHCM, BHRS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:MICHAEL
Last Name:BURDGE
Suffix:
Gender:M
Credentials:CCDC, CBHCM, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7823
Mailing Address - Country:US
Mailing Address - Phone:918-490-2270
Mailing Address - Fax:
Practice Address - Street 1:23 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6423
Practice Address - Country:US
Practice Address - Phone:918-640-0290
Practice Address - Fax:918-227-1125
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional