Provider Demographics
NPI:1407199656
Name:FEDELI, JASON BRENT (MA, LPC-S)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:BRENT
Last Name:FEDELI
Suffix:
Gender:M
Credentials:MA, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 VANGUARD DR STE 202
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-5393
Mailing Address - Country:US
Mailing Address - Phone:907-202-2527
Mailing Address - Fax:
Practice Address - Street 1:9330 VANGUARD DR STE 202
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-5393
Practice Address - Country:US
Practice Address - Phone:907-202-2527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AK119538101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK119538OtherSTATE OF ALASKA LPC LICENSE
AK2093603OtherALASKA BUSINESS LICENSE
AK1013676055OtherNPI-2