Provider Demographics
NPI:1447890744
Name:HENLEY, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HENLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 E ARROW HWY BLDG B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4996
Mailing Address - Country:US
Mailing Address - Phone:909-932-1069
Mailing Address - Fax:
Practice Address - Street 1:1260 E ARROW HWY BLDG B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4996
Practice Address - Country:US
Practice Address - Phone:909-932-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist