Provider Demographics
NPI:1093966624
Name:JONGENEELEN, KERRIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KERRIE
Middle Name:
Last Name:JONGENEELEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MUZZEY ST STE 202A
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-5211
Mailing Address - Country:US
Mailing Address - Phone:617-372-5653
Mailing Address - Fax:
Practice Address - Street 1:19 MUZZEY ST STE 202A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5211
Practice Address - Country:US
Practice Address - Phone:617-372-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10646103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071OtherGROUP #