Basic Information
| Provider Information | |||||||||
| NPI: | 1740402551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYNARD | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 CHERRYTREE LN | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232352923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049093877 | ||||||||
| FaxNumber: | 8043208738 | ||||||||
| Practice Location | |||||||||
| Address1: | 6962 FOREST HILL AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232251606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043207738 | ||||||||
| FaxNumber: | 8043208738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0710000108 | VA | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 0701000921 | VA | X | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.