Healthcare Provider Details

I. General information

NPI: 1639976368
Provider Name (Legal Business Name): JENNIFER MACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 N GLASSFORD HILL RD STE 108
PRESCOTT VALLEY AZ
86314-2256
US

IV. Provider business mailing address

700 MASSACHUSETTS AVE FL 3
CAMBRIDGE MA
02139-3345
US

V. Phone/Fax

Practice location:
  • Phone: 844-385-3747
  • Fax:
Mailing address:
  • Phone: 888-500-2067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-22672
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: