Healthcare Provider Details

I. General information

NPI: 1689466807
Provider Name (Legal Business Name): JASON RUSSELL ADAMS CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 TOD PL NW
WARREN OH
44485-2475
US

IV. Provider business mailing address

1212 TOD PL NW
WARREN OH
44485-2475
US

V. Phone/Fax

Practice location:
  • Phone: 330-469-6822
  • Fax:
Mailing address:
  • Phone: 330-469-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.189566
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: