Provider Demographics
NPI:1710526967
Name:HAYNES, JASON R (NCC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:HAYNES
Suffix:
Gender:M
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 HIGHLAND LN NE APT 1206
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4338
Mailing Address - Country:US
Mailing Address - Phone:404-314-4834
Mailing Address - Fax:
Practice Address - Street 1:3754 LAVISTA RD STE 200
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5627
Practice Address - Country:US
Practice Address - Phone:770-810-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health