Healthcare Provider Details

I. General information

NPI: 1851703425
Provider Name (Legal Business Name): MARY JESSICA HERRO I MED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY JESSICA HERRO I LPC

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 N 67TH AVE STE 400
GLENDALE AZ
85308-3698
US

IV. Provider business mailing address

17100 N 67TH AVE STE 400
GLENDALE AZ
85308-3698
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-3323
  • Fax: 602-938-1626
Mailing address:
  • Phone: 602-938-3323
  • Fax: 602-938-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2412
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: