Provider Demographics
NPI:1275760118
Name:COON-WALLMAN, JENNIFER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:COON-WALLMAN
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 1:76 BEDFORD STREET
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420
Mailing Address - Country:US
Mailing Address - Phone:781-869-1350
Mailing Address - Fax:
Practice Address - Street 1:76 BEDFORD ST
Practice Address - Street 2:SUITE 10
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4646
Practice Address - Country:US
Practice Address - Phone:781-869-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8099103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical