Provider Demographics
NPI:1700297900
Name:JENKINS-HAYDEN, LYSA MONIQUE CHRISTINE (LPC, MA, R-DMT)
Entity Type:Individual
Prefix:MS
First Name:LYSA MONIQUE
Middle Name:CHRISTINE
Last Name:JENKINS-HAYDEN
Suffix:
Gender:F
Credentials:LPC, MA, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 N 10TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3804
Mailing Address - Country:US
Mailing Address - Phone:267-368-6630
Mailing Address - Fax:
Practice Address - Street 1:6310 N 10TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3804
Practice Address - Country:US
Practice Address - Phone:267-368-6630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-11
Last Update Date:2014-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007537101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health