Provider Demographics
NPI:1154847523
Name:ELEZAJ, JESSICA MARA (LLPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARA
Last Name:ELEZAJ
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HOWARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LEONARD
Mailing Address - State:MI
Mailing Address - Zip Code:48367-1202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42815 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1143
Practice Address - Country:US
Practice Address - Phone:586-333-5328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016163101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional