Basic Information
Provider Information | |||||||||
NPI: | 1548763725 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JUNIPER | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CDCA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224 COLUMBUS RD | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | OH | ||||||||
PostalCode: | 457011334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405926724 | ||||||||
FaxNumber: | 7405926728 | ||||||||
Practice Location | |||||||||
Address1: | 18 STATE ROUTE 143 | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | OH | ||||||||
PostalCode: | 457101100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7406980131 | ||||||||
FaxNumber: | 7406980832 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2018 | ||||||||
LastUpdateDate: | 06/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 141723 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 2864002 | 05 | OH |   | MEDICAID |