Provider Demographics
NPI:1407465826
Name:JASON, POLLY L (PEER SUPPORTER)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:L
Last Name:JASON
Suffix:
Gender:F
Credentials:PEER SUPPORTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11720 EDGEWATER DR APT 816
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-6730
Mailing Address - Country:US
Mailing Address - Phone:216-798-0759
Mailing Address - Fax:
Practice Address - Street 1:11720 EDGEWATER DR APT 816
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-6730
Practice Address - Country:US
Practice Address - Phone:216-798-0759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0001575101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)