Basic Information
| Provider Information | |||||||||
| NPI: | 1811487655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HINE | ||||||||
| FirstName: | JAELA | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | MYERS | ||||||||
| OtherFirstName: | JAELA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3410 OLD FOREST RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012915 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 LANGHORNE RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245011121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349484831 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701007649 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.