MEDICARE: JAMIE RENEE HAIRSTON MS, LASAC

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
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	15285	AZ

General Provider Information

NPI Number	:	1790387603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE RENEE HAIRSTON MS, LASAC

Provider Business Mailing Address
First Line	:	3609 N ARIZONA ST
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-0749
Country	:	US
Telephone Number	:	520-561-7078
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 HUALAPAI MOUNTAIN RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-5306
Country	:	US
Telephone Number	:	928-753-2665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2020
Last Update Date	:	11/15/2020

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