Healthcare Provider Details

I. General information

NPI: 1578263554
Provider Name (Legal Business Name): JESSES HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4124 KATHERINE PL
LEXINGTON KY
40515-4000
US

IV. Provider business mailing address

2081 HARRODSBURG RD # 1117
LEXINGTON KY
40504-3503
US

V. Phone/Fax

Practice location:
  • Phone: 502-209-8025
  • Fax:
Mailing address:
  • Phone: 502-209-8025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: JOY SPICE
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 502-209-8025