Provider Demographics
NPI:1093980302
Name:DOMINICK, JILLIAN RECKE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:RECKE
Last Name:DOMINICK
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 1:7 FIFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3002
Mailing Address - Country:US
Mailing Address - Phone:617-905-3477
Mailing Address - Fax:
Practice Address - Street 1:7 FIFIELD ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3002
Practice Address - Country:US
Practice Address - Phone:617-905-3477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1145361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical