Healthcare Provider Details

I. General information

NPI: 1487107645
Provider Name (Legal Business Name): MR. CHESTER EUGENE HARRISON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 N CALIFORNIA ST STE B&C
STOCKTON CA
95204-6029
US

IV. Provider business mailing address

1644 SYCAMORE AVE
STOCKTON CA
95205-3430
US

V. Phone/Fax

Practice location:
  • Phone: 209-463-0870
  • Fax:
Mailing address:
  • Phone: 209-405-3564
  • 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: