Provider Demographics
NPI:1912790650
Name:TIVADE, JASON
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:TIVADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9810 COTTRELL TER
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1917
Mailing Address - Country:US
Mailing Address - Phone:240-304-0043
Mailing Address - Fax:
Practice Address - Street 1:2905 MITCHELLVILLE RD STE 204
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3961
Practice Address - Country:US
Practice Address - Phone:301-701-6965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212283163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health