Provider Demographics
NPI:1699278523
Name:PRENDERGAST, JASON-ANTHONY KIRKHAM
Entity type:Individual
Prefix:DR
First Name:JASON-ANTHONY
Middle Name:KIRKHAM
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4163 NW 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4716
Mailing Address - Country:US
Mailing Address - Phone:954-383-3776
Mailing Address - Fax:
Practice Address - Street 1:1451 W CYPRESS CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1961
Practice Address - Country:US
Practice Address - Phone:888-773-3439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17769101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral