Provider Demographics
NPI:1396111035
Name:POLK, JASON (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:POLK
Suffix:
Gender:M
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W 9TH AVE UNIT 2513
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4054
Mailing Address - Country:US
Mailing Address - Phone:720-272-9573
Mailing Address - Fax:
Practice Address - Street 1:190 E 9TH AVE STE 395
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-2736
Practice Address - Country:US
Practice Address - Phone:720-272-9573
Practice Address - Fax:303-830-6707
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000426101YA0400X
COCSW.099239051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)