Provider Demographics
NPI:1538626809
Name:JACKSON-HARRIS, CHASE VAUGHN
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:VAUGHN
Last Name:JACKSON-HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHASE
Other - Middle Name:VAUGHN
Other - Last Name:JACKSOM-HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:17535 DARBY LN
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4817
Mailing Address - Country:US
Mailing Address - Phone:813-485-8444
Mailing Address - Fax:813-512-6426
Practice Address - Street 1:17535 DARBY LN
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4817
Practice Address - Country:US
Practice Address - Phone:813-485-8444
Practice Address - Fax:813-512-6426
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician