Provider Demographics
NPI:1962538785
Name:HARRIS, JIM KEITH (LCSW)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:KEITH
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 WENDAN DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5550
Mailing Address - Country:US
Mailing Address - Phone:770-242-2340
Mailing Address - Fax:
Practice Address - Street 1:1834 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3405
Practice Address - Country:US
Practice Address - Phone:770-242-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0014911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR13094Medicare UPIN