Provider Demographics
NPI:1396565487
Name:POLATIS, JARED RANDALL (LMFTA)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:RANDALL
Last Name:POLATIS
Suffix:
Gender:M
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7824 GREEN LEVEL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27523-9466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 CHAPEL RIDGE RD STE 220
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-8627
Practice Address - Country:US
Practice Address - Phone:919-355-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20253A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist