Basic Information
Provider Information | |||||||||
NPI: | 1467911271 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | JASMINE | ||||||||
MiddleName: | TASHAE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARRIS | ||||||||
OtherFirstName: | JASMINE | ||||||||
OtherMiddleName: | TASHAE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1110 CLAY ST | ||||||||
Address2: |   | ||||||||
City: | VICKSBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 391832912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017385820 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1111 SH-6 N | ||||||||
Address2: | SUITE 120 | ||||||||
City: | SUGAR LAND | ||||||||
State: | TX | ||||||||
PostalCode: | 77478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2817692238 | ||||||||
FaxNumber: | 2817692164 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2019 | ||||||||
LastUpdateDate: | 07/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YP2500X | 84552 | TX | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.