Basic Information
| Provider Information | |||||||||
| NPI: | 1689914962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | DREW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 192 | ||||||||
| Address2: | |||||||||
| City: | FALLSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280420192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048426476 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2505 COURT DR # B | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048426476 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2013 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P007872 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.