Provider Demographics
NPI:1518420454
Name:MAZA, JESSICA LAUREN (MHC-LP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LAUREN
Last Name:MAZA
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2423
Mailing Address - Country:US
Mailing Address - Phone:718-813-9816
Mailing Address - Fax:
Practice Address - Street 1:2291 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6625
Practice Address - Country:US
Practice Address - Phone:718-569-7314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health