Provider Demographics
NPI:1194885228
Name:KUSIC, JASON MICHAEL (LSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:KUSIC
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 WASHINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1962
Mailing Address - Country:US
Mailing Address - Phone:304-737-0925
Mailing Address - Fax:304-737-0925
Practice Address - Street 1:494 WASHINGTON PIKE
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1962
Practice Address - Country:US
Practice Address - Phone:304-737-0925
Practice Address - Fax:304-737-0925
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW125329104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker