Provider Demographics
NPI:1558852038
Name:CHEATHAM, JARID ISAIAH (CASAC #31237)
Entity Type:Individual
Prefix:MR
First Name:JARID
Middle Name:ISAIAH
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:CASAC #31237
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 BADEN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-2054
Mailing Address - Country:US
Mailing Address - Phone:585-325-4910
Mailing Address - Fax:585-546-1491
Practice Address - Street 1:585 JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-1215
Practice Address - Country:US
Practice Address - Phone:585-325-4910
Practice Address - Fax:585-546-1491
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321237101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor