Provider Demographics
NPI:1255669347
Name:TIESO, JACQUELINE ELIZABETH (LICSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:TIESO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ELIZABETH
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:455 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:MA
Mailing Address - Zip Code:02370-1250
Mailing Address - Country:US
Mailing Address - Phone:781-871-0531
Mailing Address - Fax:
Practice Address - Street 1:455 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-1250
Practice Address - Country:US
Practice Address - Phone:781-871-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1151171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical