Provider Demographics
NPI:1548488919
Name:CUNNINGHAM, JASON TY (LMFT, LPC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:TY
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 ROBERT BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-1345
Mailing Address - Country:US
Mailing Address - Phone:985-649-2774
Mailing Address - Fax:985-649-2738
Practice Address - Street 1:480 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1345
Practice Address - Country:US
Practice Address - Phone:985-649-2774
Practice Address - Fax:985-649-2738
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2412101YP2500X
LAMFT25106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist