Provider Demographics
NPI:1275994998
Name:LARA, JESENIA MERCEDES
Entity Type:Individual
Prefix:
First Name:JESENIA
Middle Name:MERCEDES
Last Name:LARA
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 1:50 REDFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3630
Mailing Address - Country:US
Mailing Address - Phone:617-469-8500
Mailing Address - Fax:
Practice Address - Street 1:50 REDFIELD ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3630
Practice Address - Country:US
Practice Address - Phone:617-469-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor