Basic Information
| Provider Information | |||||||||
| NPI: | 1598361107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAINES | ||||||||
| FirstName: | JILLIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3103 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450151653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138924673 | ||||||||
| FaxNumber: | 5137371107 | ||||||||
| Practice Location | |||||||||
| Address1: | 3103 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450151653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138924673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2020 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0800X | N | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care | 175T00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 117440361 | 05 | OH | MEDICAID | 87860667 | 05 | OH | MEDICAID |