Provider Demographics
NPI:1437541752
Name:SUSTAR, JENNIFER (LPCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SUSTAR
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8775 EAST AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4303
Mailing Address - Country:US
Mailing Address - Phone:440-290-9914
Mailing Address - Fax:
Practice Address - Street 1:8775 EAST AVE STE B
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4303
Practice Address - Country:US
Practice Address - Phone:440-290-9914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1400617-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2844093Medicaid