Provider Demographics
NPI:1902685464
Name:ELLER, JASON R (LICSWA, MSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:ELLER
Suffix:
Gender:M
Credentials:LICSWA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 ANDRESS ST NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3404
Mailing Address - Country:US
Mailing Address - Phone:719-287-5545
Mailing Address - Fax:
Practice Address - Street 1:4200 6TH AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1042
Practice Address - Country:US
Practice Address - Phone:564-669-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WASC61356908104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASC61356908OtherWASHINGTON STATE DEPARTMENT OF HEALTH