Provider Demographics
NPI:1245359215
Name:LAZER, JESSICA J (PHD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:LAZER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 BUFORD HWY NE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2149
Mailing Address - Country:US
Mailing Address - Phone:404-633-3633
Mailing Address - Fax:
Practice Address - Street 1:2801 BUFORD HWY NE
Practice Address - Street 2:SUITE 275
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2149
Practice Address - Country:US
Practice Address - Phone:404-633-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002141103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S43371Medicare UPIN
GA68BBFWVMedicare ID - Type Unspecified