MEDICARE: LA VERNE JASMINE HARRIS CADC-CAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	C034390315	CA

General Provider Information

NPI Number	:	1841686011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LA VERNE JASMINE HARRIS CADC-CAS

Provider Business Mailing Address
First Line	:	77 EMERALD CT
Second Line	:
City	:	GALT
State	:	CA
Zip	:	95632-2306
Country	:	US
Telephone Number	:	209-912-8233
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 SPORTS DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1943
Country	:	US
Telephone Number	:	916-575-8851
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2015
Last Update Date	:	04/14/2015

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