Provider Demographics
NPI:1548564495
Name:JARVIS, VICKIE L (MA, PCC)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:L
Last Name:JARVIS
Suffix:
Gender:F
Credentials:MA, PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:OH
Mailing Address - Zip Code:44822-0353
Mailing Address - Country:US
Mailing Address - Phone:419-565-5825
Mailing Address - Fax:
Practice Address - Street 1:1140 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2254
Practice Address - Country:US
Practice Address - Phone:419-565-5825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0500279101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health