Provider Demographics
NPI:1164744280
Name:CONNELLY, JESSICA SLAVIN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:SLAVIN
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:IRENE
Other - Last Name:SLAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:17 COREY RD
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-1116
Mailing Address - Country:US
Mailing Address - Phone:617-512-8085
Mailing Address - Fax:
Practice Address - Street 1:17 COREY RD
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-1116
Practice Address - Country:US
Practice Address - Phone:617-512-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1157271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical