Basic Information
| Provider Information | |||||||||
| NPI: | 1225097553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIERSTEIN | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2702 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850044608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233407 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 N COFCO CENTER CT | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850086462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023238200 | ||||||||
| FaxNumber: | 6022860808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LPC-11914 | AZ | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 922717 | 05 | AZ | MEDICAID |