Provider Demographics
NPI:1548748494
Name:LAZOS, JESSICA (LMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAZOS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68680 DINAH SHORE DR APT 20B
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-5721
Mailing Address - Country:US
Mailing Address - Phone:760-574-8414
Mailing Address - Fax:442-300-2118
Practice Address - Street 1:78401 HIGHWAY 111 STE U
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2066
Practice Address - Country:US
Practice Address - Phone:760-289-5295
Practice Address - Fax:442-300-2118
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107155106H00000X
CA129101106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist