Provider Demographics
NPI:1295027415
Name:SHAH, JESSIE ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:ANNE
Last Name:SHAH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JESSIE
Other - Middle Name:ANNE
Other - Last Name:FONTANELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:8 GROVE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7739
Mailing Address - Country:US
Mailing Address - Phone:857-626-6995
Mailing Address - Fax:
Practice Address - Street 1:8 GROVE ST STE 300
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-7739
Practice Address - Country:US
Practice Address - Phone:857-626-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9825103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist