Provider Demographics
NPI:1093460370
Name:AGENOR, JESSICA I
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:I
Last Name:AGENOR
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 1:73 PORTER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-2872
Mailing Address - Country:US
Mailing Address - Phone:781-957-8713
Mailing Address - Fax:
Practice Address - Street 1:1R NEWBURY ST STE 401
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-3816
Practice Address - Country:US
Practice Address - Phone:671-804-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health