Healthcare Provider Details

I. General information

NPI: 1467046755
Provider Name (Legal Business Name): JEANETTE LEAL MAZON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W THOMAS RD STE 320
PHOENIX AZ
85013-4415
US

IV. Provider business mailing address

124 W THOMAS RD STE 320
PHOENIX AZ
85013-4415
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-8521
  • Fax: 602-406-1011
Mailing address:
  • Phone: 602-406-8521
  • Fax: 602-406-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19165
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: