Provider Demographics
NPI:1487383295
Name:LESSARD, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:LESSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY JANE
Other - Middle Name:NONE
Other - Last Name:LESSARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1819 S DOBSON RD STE 115
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-5656
Mailing Address - Country:US
Mailing Address - Phone:480-787-1955
Mailing Address - Fax:
Practice Address - Street 1:1819 S DOBSON RD STE 115
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5656
Practice Address - Country:US
Practice Address - Phone:480-787-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15474101YM0800X
AZ10652101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health