Provider Demographics
NPI:1518461375
Name:AVIS, JAMIE L (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:L
Last Name:AVIS
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 1:521 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1122
Mailing Address - Country:US
Mailing Address - Phone:303-931-7406
Mailing Address - Fax:
Practice Address - Street 1:164 W WATER ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-1332
Practice Address - Country:US
Practice Address - Phone:303-931-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2001783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0294147Medicaid