Provider Demographics
NPI:1083816805
Name:MICCO, JAMIE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:A
Last Name:MICCO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 MAIN ST STE 324
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3329
Mailing Address - Country:US
Mailing Address - Phone:978-405-2544
Mailing Address - Fax:
Practice Address - Street 1:747 MAIN ST
Practice Address - Street 2:SUITE 119
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3302
Practice Address - Country:US
Practice Address - Phone:978-505-6684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8826103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical