Provider Demographics
NPI:1114387685
Name:CUNNINGHAM, JASON (LPCC, LICDC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:LPCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:440-989-4900
Mailing Address - Fax:440-282-4779
Practice Address - Street 1:2115 W PARK DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1138
Practice Address - Country:US
Practice Address - Phone:440-989-4987
Practice Address - Fax:440-282-4779
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2003043101YM0800X
101YM0800X
OHE.2303364101YM0800X
OH1312443101YA0400X
OHLICDC.162045101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0383469Medicaid
OHLICDC.162045OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD