Basic Information
| Provider Information | |||||||||
| NPI: | 1356855860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARSTEN | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8411 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441053932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164410200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 246 NORTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307259195 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | S.1601237 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | CDCA.130385 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | S.1601237 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0293619 | 05 | OH | MEDICAID |