Provider Demographics
NPI:1740780204
Name:JAY BASTIAN LLC
Entity Type:Organization
Organization Name:JAY BASTIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:260-570-4515
Mailing Address - Street 1:9910 DUPONT CIRCLE DR. SUITE 140
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1610
Mailing Address - Country:US
Mailing Address - Phone:260-570-4515
Mailing Address - Fax:260-209-0762
Practice Address - Street 1:9910 DUPONT CIRCLE DR. SUITE 140
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1610
Practice Address - Country:US
Practice Address - Phone:260-570-4515
Practice Address - Fax:260-209-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007970A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty