Basic Information
| Provider Information | |||||||||
| NPI: | 1700247962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAZARIS | ||||||||
| FirstName: | JENELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3694 CLARKSTON RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483485213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484100650 | ||||||||
| FaxNumber: | 2483917478 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 S MAIN ST | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344543560 | ||||||||
| FaxNumber: | 7344543570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 4101006577 | MI | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.