Provider Demographics
NPI:1336614072
Name:JASON MUZZILLO, PLLC
Entity type:Organization
Organization Name:JASON MUZZILLO, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MUZZILLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:859-305-1430
Mailing Address - Street 1:168 E REYNOLDS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1360
Mailing Address - Country:US
Mailing Address - Phone:859-322-9222
Mailing Address - Fax:
Practice Address - Street 1:168 E REYNOLDS RD STE 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-1360
Practice Address - Country:US
Practice Address - Phone:859-305-1430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100614860Medicaid
KY7100515530Medicaid