Provider Demographics
NPI:1326414079
Name:ROSA, JASON (LCSW)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:ROSA
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 1:512 BROOKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-2578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 BROOKLAWN AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-2578
Practice Address - Country:US
Practice Address - Phone:678-367-9537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056346001041C0700X
GACSW0052721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical