Provider Demographics
NPI:1053734897
Name:PHELAN, JASON ROBERT (BA-ADP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:PHELAN
Suffix:
Gender:M
Credentials:BA-ADP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-1158
Mailing Address - Country:US
Mailing Address - Phone:410-535-3079
Mailing Address - Fax:410-535-2220
Practice Address - Street 1:975 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3917
Practice Address - Country:US
Practice Address - Phone:410-535-3079
Practice Address - Fax:410-535-2220
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)