Provider Demographics
NPI:1790268936
Name:CIVIELLO, JESSICA A
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:CIVIELLO
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 1:7227 E BASELINE RD STE 126
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-5006
Mailing Address - Country:US
Mailing Address - Phone:480-868-9650
Mailing Address - Fax:480-834-3606
Practice Address - Street 1:7227 E BASELINE RD STE 126
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-5006
Practice Address - Country:US
Practice Address - Phone:480-868-9650
Practice Address - Fax:480-834-3606
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-17233104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker