Healthcare Provider Details

I. General information

NPI: 1114387685
Provider Name (Legal Business Name): JASON CUNNINGHAM LPCC, LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 W PARK DR
LORAIN OH
44053-1138
US

IV. Provider business mailing address

2115 W PARK DR
LORAIN OH
44053-1138
US

V. Phone/Fax

Practice location:
  • Phone: 440-989-4987
  • Fax: 440-282-4779
Mailing address:
  • Phone: 440-989-4900
  • Fax: 440-282-4779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2003043
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2303364
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1312443
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162045
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: