Provider Demographics
NPI:1306282223
Name:STAUFFER, JASON J
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:STAUFFER
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 1:2121 TOWN RDG
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1649
Mailing Address - Country:US
Mailing Address - Phone:718-869-0102
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1036
Practice Address - Country:US
Practice Address - Phone:604-301-3408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-18
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670387121174400000X
CT629103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist