Basic Information
| Provider Information | |||||||||
| NPI: | 1417033895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRMAN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | CARTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165167114 | ||||||||
| FaxNumber: | 8164377399 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165167114 | ||||||||
| FaxNumber: | 8164377399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 05/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2004033756 | MO | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 191215 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 498452606 | 05 | MO | MEDICAID |