Provider Demographics
NPI:1720558455
Name:HARRISON, KETHA JEROME SR
Entity Type:Individual
Prefix:MR
First Name:KETHA
Middle Name:JEROME
Last Name:HARRISON
Suffix:SR
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 1:316 N MICHIGAN ST STE 923
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-5667
Mailing Address - Country:US
Mailing Address - Phone:567-219-1149
Mailing Address - Fax:
Practice Address - Street 1:316 N MICHIGAN ST STE 923
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-5667
Practice Address - Country:US
Practice Address - Phone:567-219-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)