Healthcare Provider Details

I. General information

NPI: 1790387603
Provider Name (Legal Business Name): JAMIE RENEE HAIRSTON MS, LASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 HUALAPAI MOUNTAIN RD
KINGMAN AZ
86401-5306
US

IV. Provider business mailing address

3609 N ARIZONA ST
KINGMAN AZ
86409-0749
US

V. Phone/Fax

Practice location:
  • Phone: 928-753-2665
  • Fax:
Mailing address:
  • Phone: 520-561-7078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15285
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: