Basic Information
Provider Information | |||||||||
NPI: | 1720459480 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EASON | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 CHAMBER CENTER DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LAKESIDE PARK | ||||||||
State: | KY | ||||||||
PostalCode: | 410171686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593015901 | ||||||||
FaxNumber: | 8593015940 | ||||||||
Practice Location | |||||||||
Address1: | 200 MEDICAL VILLAGE DR | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593015901 | ||||||||
FaxNumber: | 8593015940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2015 | ||||||||
LastUpdateDate: | 04/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3196 | KY | Y |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 3196 | KY | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 7100374360 | 05 | KY |   | MEDICAID | 0155189 | 05 | OH |   | MEDICAID |