Provider Demographics
NPI:1225415110
Name:BUNNELL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BUNNELL
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 1:48 ENGLEHUTT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2542
Mailing Address - Country:US
Mailing Address - Phone:603-568-8382
Mailing Address - Fax:
Practice Address - Street 1:331 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01850-1857
Practice Address - Country:US
Practice Address - Phone:978-656-8546
Practice Address - Fax:978-746-8916
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-19-39195103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst