Basic Information
| Provider Information | |||||||||
| NPI: | 1285874081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAIRSTON | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED., LPCC-S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLACK | ||||||||
| OtherFirstName: | JAN | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5930 HEISLEY RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440601834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403549924 | ||||||||
| FaxNumber: | 4403545808 | ||||||||
| Practice Location | |||||||||
| Address1: | 5930 HEISLEY RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440601834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403549924 | ||||||||
| FaxNumber: | 4403545808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2009 | ||||||||
| LastUpdateDate: | 03/06/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | E0001655 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | E0001655 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.