Provider Demographics
NPI:1871153197
Name:LAZENBY, JESSICA CHENILLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHENILLE
Last Name:LAZENBY
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 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:2129 STATESVILLE BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1411
Practice Address - Country:US
Practice Address - Phone:704-633-3616
Practice Address - Fax:704-633-5902
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0136241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical