Provider Demographics
NPI:1780129064
Name:HAIRE, JORDAN E
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:E
Last Name:HAIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 N YELLOW SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2463
Mailing Address - Country:US
Mailing Address - Phone:937-399-9500
Mailing Address - Fax:937-342-4242
Practice Address - Street 1:100 WELLNESS WAY
Practice Address - Street 2:410
Practice Address - City:NEAH BAY
Practice Address - State:WA
Practice Address - Zip Code:98357-9835
Practice Address - Country:US
Practice Address - Phone:360-645-3010
Practice Address - Fax:360-645-3343
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1200640101YP2500X
WALH60728422101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional