Provider Demographics
NPI:1588973564
Name:HALLER, JENIFER MARY (PCC)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:MARY
Last Name:HALLER
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6931 MIDDLEBRANCH AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2637
Mailing Address - Country:US
Mailing Address - Phone:330-354-9286
Mailing Address - Fax:
Practice Address - Street 1:37 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1910
Practice Address - Country:US
Practice Address - Phone:330-535-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E.0900634101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2098340Medicaid