Provider Demographics
NPI:1720518327
Name:KIRK, JASON MATTHEW (MA, LPC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:KIRK
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W TOWNSHIP LINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4930
Mailing Address - Country:US
Mailing Address - Phone:610-708-0721
Mailing Address - Fax:267-285-1994
Practice Address - Street 1:1120 W TOWNSHIP LINE RD STE 101
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4930
Practice Address - Country:US
Practice Address - Phone:610-708-0721
Practice Address - Fax:267-285-1994
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009646101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional