Provider Demographics
NPI:1083999338
Name:LEVIN, JACK BRIAN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:BRIAN
Last Name:LEVIN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 LEACH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-4710
Mailing Address - Country:US
Mailing Address - Phone:617-417-4535
Mailing Address - Fax:
Practice Address - Street 1:800 W CUMMINGS PARK
Practice Address - Street 2:SUITE 3000
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6372
Practice Address - Country:US
Practice Address - Phone:617-417-4535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1181441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical