Basic Information
| Provider Information | |||||||||
| NPI: | 1578071841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARIANO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 N CLINTON AVE APT 5 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488791529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169156548 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4572 S HAGADORN RD | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174812133 | ||||||||
| FaxNumber: | 5176595934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.