Provider Demographics
NPI:1043272164
Name:JIRAK, MAYRA LORENA (LPC)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:LORENA
Last Name:JIRAK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:602-279-5390
Practice Address - Street 1:2423 W. DUNLAP AVE., SUITE 140
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2830
Practice Address - Country:US
Practice Address - Phone:602-279-5351
Practice Address - Fax:602-279-5361
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-11608101Y00000X
AZLISAC-11404101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ994609Medicaid