Provider Demographics
NPI:1699119735
Name:MASON, JESSEY L
Entity type:Individual
Prefix:
First Name:JESSEY
Middle Name:L
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1108
Mailing Address - Country:US
Mailing Address - Phone:317-686-5634
Mailing Address - Fax:
Practice Address - Street 1:832 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1108
Practice Address - Country:US
Practice Address - Phone:317-686-5634
Practice Address - Fax:317-287-3739
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006695A1041C0700X
IN87000782A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)