Provider Demographics
NPI:1255115523
Name:MIZE, JERRY LEE II
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:MIZE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 POPLAR HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-2172
Mailing Address - Country:US
Mailing Address - Phone:804-691-6957
Mailing Address - Fax:
Practice Address - Street 1:2709 POPLAR HAVEN CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-2172
Practice Address - Country:US
Practice Address - Phone:804-691-6957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health