Provider Demographics
NPI:1104345586
Name:JAENISH, LAURA (LPC, NCC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JAENISH
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8005
Mailing Address - Country:US
Mailing Address - Phone:480-266-0121
Mailing Address - Fax:
Practice Address - Street 1:4111 E VALLEY AUTO DR STE 209
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4609
Practice Address - Country:US
Practice Address - Phone:602-730-5089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2017-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health