Healthcare Provider Details

I. General information

NPI: 1043784739
Provider Name (Legal Business Name): CHARLES MATTHEW JASON HARGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SOUTHERN AVE
MESA AZ
85206-2569
US

IV. Provider business mailing address

PO BOX 653
WADDELL AZ
85355-0653
US

V. Phone/Fax

Practice location:
  • Phone: 623-738-6737
  • Fax:
Mailing address:
  • Phone: 623-738-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-23000
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: