Provider Demographics
NPI:1073819082
Name:BOGNANNO, JENNIFER MICHELLE MARRAM (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE MARRAM
Last Name:BOGNANNO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-0207
Mailing Address - Country:US
Mailing Address - Phone:781-801-2809
Mailing Address - Fax:
Practice Address - Street 1:215 MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4328
Practice Address - Country:US
Practice Address - Phone:508-897-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216599101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA117526OtherCOMMONWEALTH OF MASSACHUSETTS