Basic Information
| Provider Information | |||||||||
| NPI: | 1639659410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | URDA | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MSED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9305 MONROE RD STE L | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282701490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9808190010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10926 S TRYON ST STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552015498 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | NC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.