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NPI Code Detail

MEDICARE: JAY BASTIAN LLC

MEDICARE: JAY BASTIAN LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker34007970AIN

General Provider Information

NPI Number : 1740780204
Entity Type Code : Organization
Provider Name (Legal Business Name) : JAY BASTIAN LLC
Provider Business Mailing Address
First Line : 9329 ILLINOIS RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-5796
Country : US
Telephone Number : 260-418-9653
Fax Number : 260-209-0762
Provider Business Practice Location Address
First Line : 9329 ILLINOIS RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-5796
Country : US
Telephone Number : 260-418-9653
Fax Number :
Authorized Official
Title or Position : PSYCHOTHERAPIST
Name : MR. JAY ALAN BASTIAN
Credential : LCSW
Telephone Number : 260-418-9653
Provider Enumeration Date : 02/20/2018
Last Update Date : 10/26/2024

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