Provider Demographics
NPI:1760658314
Name:KING, JASON CHARLES (PSYD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:CHARLES
Last Name:KING
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 MAPLE AVE
Mailing Address - Street 2:2E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1262
Mailing Address - Country:US
Mailing Address - Phone:708-699-1670
Mailing Address - Fax:847-570-6083
Practice Address - Street 1:1599 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4367
Practice Address - Country:US
Practice Address - Phone:708-699-1670
Practice Address - Fax:847-570-6083
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007455103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical