Provider Demographics
NPI:1215164835
Name:MCCOY, JASON M (LCSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:MCCOY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 WESTERN CENTER BLVD
Mailing Address - Street 2:STE. 211
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1939
Mailing Address - Country:US
Mailing Address - Phone:469-999-3208
Mailing Address - Fax:
Practice Address - Street 1:3629 WESTERN CENTER BLVD
Practice Address - Street 2:STE. 211
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1939
Practice Address - Country:US
Practice Address - Phone:817-232-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007307104100000X
TX559301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker