Provider Demographics
NPI:1073270328
Name:LESSER, JEREMY B (LAC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:B
Last Name:LESSER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 E VAN BUREN ST UNIT 2013
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-3461
Mailing Address - Country:US
Mailing Address - Phone:732-977-6527
Mailing Address - Fax:
Practice Address - Street 1:300 W CLARENDON AVE STE 470
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3475
Practice Address - Country:US
Practice Address - Phone:602-345-1502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty