Provider Demographics
NPI:1295289551
Name:JUSTICE, TIFFANY MARIE (LPCC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E HURON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1976
Mailing Address - Country:US
Mailing Address - Phone:740-935-4085
Mailing Address - Fax:
Practice Address - Street 1:135 E HURON ST STE 111
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1976
Practice Address - Country:US
Practice Address - Phone:740-935-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1200442101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0213093Medicaid