Healthcare Provider Details

I. General information

NPI: 1558852038
Provider Name (Legal Business Name): JARID ISAIAH CHEATHAM CASAC #31237
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 JOSEPH AVE
ROCHESTER NY
14605-1215
US

IV. Provider business mailing address

152 BADEN ST
ROCHESTER NY
14605-2054
US

V. Phone/Fax

Practice location:
  • Phone: 585-325-4910
  • Fax: 585-546-1491
Mailing address:
  • Phone: 585-325-4910
  • Fax: 585-546-1491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number321237
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: