Provider Demographics
NPI:1932832755
Name:HARRIS, JASON VIDAL (CDCA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:VIDAL
Last Name:HARRIS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 PROSPECT AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2322
Mailing Address - Country:US
Mailing Address - Phone:216-781-2121
Mailing Address - Fax:
Practice Address - Street 1:1710 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2322
Practice Address - Country:US
Practice Address - Phone:216-781-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA181132101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor