Provider Demographics
NPI:1396597217
Name:FAIR, JONAH (TLLPC, LLPC)
Entity type:Individual
Prefix:
First Name:JONAH
Middle Name:
Last Name:FAIR
Suffix:
Gender:M
Credentials:TLLPC, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PARKLANE BLVD STE 122
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4206
Mailing Address - Country:US
Mailing Address - Phone:313-649-7382
Mailing Address - Fax:
Practice Address - Street 1:6 PARKLANE BLVD STE 122
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4206
Practice Address - Country:US
Practice Address - Phone:313-649-7382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023162101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional