Provider Demographics
NPI:1578279782
Name:PICKENS, JANINE W
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:W
Last Name:PICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 N MAIN ST # NA
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3455
Mailing Address - Country:US
Mailing Address - Phone:937-277-9610
Mailing Address - Fax:
Practice Address - Street 1:5524 N MAIN ST # NA
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3455
Practice Address - Country:US
Practice Address - Phone:937-277-9610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health