Provider Demographics
NPI:1639976368
Name:MACIAS, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MACIAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MASSACHUSETTS AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3345
Mailing Address - Country:US
Mailing Address - Phone:888-500-2067
Mailing Address - Fax:
Practice Address - Street 1:112 N CENTRAL AVE STE M43
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2309
Practice Address - Country:US
Practice Address - Phone:888-500-2067
Practice Address - Fax:617-649-8520
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22672101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional