Provider Demographics
NPI:1285232785
Name:MAEZ, JESSICA LIANNA (EDM, MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LIANNA
Last Name:MAEZ
Suffix:
Gender:F
Credentials:EDM, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 HOKULANI ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-1024
Mailing Address - Country:US
Mailing Address - Phone:646-248-8744
Mailing Address - Fax:
Practice Address - Street 1:346 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3905
Practice Address - Country:US
Practice Address - Phone:646-248-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190156571103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool