Healthcare Provider Details

I. General information

NPI: 1477279727
Provider Name (Legal Business Name): JOVONDA HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 SONOMA AVE
SEASIDE CA
93955-5218
US

IV. Provider business mailing address

1779 SOTO ST APT B
SEASIDE CA
93955-3941
US

V. Phone/Fax

Practice location:
  • Phone: 725-247-8138
  • Fax:
Mailing address:
  • Phone: 725-247-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: