Provider Demographics
NPI:1477026789
Name:JARVIS, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:JARVIS
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 1:1576 TAYLOR AVE APT 4K
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-3363
Mailing Address - Country:US
Mailing Address - Phone:347-765-4941
Mailing Address - Fax:
Practice Address - Street 1:764 E 176TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4606
Practice Address - Country:US
Practice Address - Phone:718-542-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)