Provider Demographics
NPI:1285874081
Name:HAIRSTON, JAN A (MED, LPCC-S)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:A
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:MED, LPCC-S
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:A
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5930 HEISLEY RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1834
Mailing Address - Country:US
Mailing Address - Phone:440-354-9924
Mailing Address - Fax:440-354-5808
Practice Address - Street 1:5930 HEISLEY RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-1834
Practice Address - Country:US
Practice Address - Phone:440-354-9924
Practice Address - Fax:440-354-5808
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0001655101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health