Healthcare Provider Details

I. General information

NPI: 1144199837
Provider Name (Legal Business Name): JAIDA SERENITYRAIN FACKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5386 COX SMITH RD
MASON OH
45040-6803
US

IV. Provider business mailing address

4682 KIRBY AVE
CINCINNATI OH
45223-1544
US

V. Phone/Fax

Practice location:
  • Phone: 513-972-5120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2507243-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: