Healthcare Provider Details

I. General information

NPI: 1396565487
Provider Name (Legal Business Name): JARED RANDALL POLATIS LMFTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 CHAPEL RIDGE RD STE 220
APEX NC
27502-8627
US

IV. Provider business mailing address

7824 GREEN LEVEL CHURCH RD
APEX NC
27523-9466
US

V. Phone/Fax

Practice location:
  • Phone: 919-355-9792
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number20253A
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: