Provider Demographics
NPI:1952977530
Name:MAZEN, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MAZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S POPLAR ST APT 1604
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-0105
Mailing Address - Country:US
Mailing Address - Phone:813-416-6680
Mailing Address - Fax:
Practice Address - Street 1:6701 GEORGIA AVENUE
Practice Address - Street 2:
Practice Address - City:SILVER SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:20910
Practice Address - Country:US
Practice Address - Phone:301-392-7075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician