Provider Demographics
NPI:1871175307
Name:BURRIS, JASON JON (MS, LISAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:JON
Last Name:BURRIS
Suffix:
Gender:M
Credentials:MS, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 RAMAR RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6215
Mailing Address - Country:US
Mailing Address - Phone:928-266-9024
Mailing Address - Fax:
Practice Address - Street 1:3505 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3071
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-6894T101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)