Provider Demographics
NPI:1487323390
Name:MAZARIEGOS, JAILENE STACEY
Entity type:Individual
Prefix:
First Name:JAILENE
Middle Name:STACEY
Last Name:MAZARIEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 COSTELLO AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4827
Mailing Address - Country:US
Mailing Address - Phone:818-808-7836
Mailing Address - Fax:
Practice Address - Street 1:330 N MACLAY AVE STE 206
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2955
Practice Address - Country:US
Practice Address - Phone:818-351-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist