Provider Demographics
NPI:1790387603
Name:HAIRSTON, JAMIE RENEE (MS, LASAC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:RENEE
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:MS, LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 N ARIZONA ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0749
Mailing Address - Country:US
Mailing Address - Phone:520-561-7078
Mailing Address - Fax:
Practice Address - Street 1:3240 HUALAPAI MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5306
Practice Address - Country:US
Practice Address - Phone:928-753-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15285101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)