Provider Demographics
NPI:1689162612
Name:MORRIS, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MORRIS
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 1:612 N GREENE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2024
Mailing Address - Country:US
Mailing Address - Phone:336-390-2244
Mailing Address - Fax:
Practice Address - Street 1:612 N GREENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2024
Practice Address - Country:US
Practice Address - Phone:336-390-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15767101YA0400X, 101YM0800X
NC13903101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13903OtherNCBLPC