Provider Demographics
NPI:1962236737
Name:JASPER, MIKE DEVA (LCAS-A)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:DEVA
Last Name:JASPER
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13406 TARTARIAN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-3973
Mailing Address - Country:US
Mailing Address - Phone:980-704-2217
Mailing Address - Fax:
Practice Address - Street 1:2300 SARDIS RD N STE M
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7712
Practice Address - Country:US
Practice Address - Phone:704-798-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)