Healthcare Provider Details

I. General information

NPI: 1891838454
Provider Name (Legal Business Name): JASON HARRIS RADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W MAIN ST
MADISON WI
53715-1424
US

IV. Provider business mailing address

6420 OFFSHORE DR
MADISON WI
53705-4375
US

V. Phone/Fax

Practice location:
  • Phone: 608-371-7702
  • Fax:
Mailing address:
  • Phone: 608-371-7702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14134
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: