Basic Information
| Provider Information | |||||||||
| NPI: | 1508371238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARDY | ||||||||
| FirstName: | JAMILA | ||||||||
| MiddleName: | SHAFAWN | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1238 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441464525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164509557 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1320 WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167272086 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2017 | ||||||||
| LastUpdateDate: | 08/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | N | 101YA0400X | 165745 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 165745 | 01 | OH | OHIO BOARD OF COUNELORS | OTHER |