Provider Demographics
NPI:1053854562
Name:MACIAS, JENNIFER ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MACIAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2706
Mailing Address - Country:US
Mailing Address - Phone:323-386-3100
Mailing Address - Fax:
Practice Address - Street 1:1015 THORNCREST DR
Practice Address - Street 2:
Practice Address - City:FLETCHER
Practice Address - State:NC
Practice Address - Zip Code:28732-9294
Practice Address - Country:US
Practice Address - Phone:323-386-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0135691041C0700X
CA904371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical