Basic Information
Provider Information | |||||||||
NPI: | 1518493394 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAY HASH LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOPESOURCE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 GALLIA ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | PORTSMOUTH | ||||||||
State: | OH | ||||||||
PostalCode: | 456624035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403534673 | ||||||||
FaxNumber: | 7403535800 | ||||||||
Practice Location | |||||||||
Address1: | 800 GALLIA ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | PORTSMOUTH | ||||||||
State: | OH | ||||||||
PostalCode: | 456624035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403534673 | ||||||||
FaxNumber: | 7403535800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2017 | ||||||||
LastUpdateDate: | 05/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HASH | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | LAWLER | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7407271520 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPCC-S LICDC-CS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 01-7576 | OH | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 0144728 | 05 | OH |   | MEDICAID |