Provider Demographics
NPI:1689023335
Name:DISTIN, JEFFREY (PCC-S)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:DISTIN
Suffix:
Gender:M
Credentials:PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8411 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-3932
Mailing Address - Country:US
Mailing Address - Phone:216-206-5201
Mailing Address - Fax:216-441-3637
Practice Address - Street 1:8411 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-3932
Practice Address - Country:US
Practice Address - Phone:216-206-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0600654101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional