Provider Demographics
NPI:1326516402
Name:JACKMAN, BONNIE ELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ELLEN
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:ORLEANS
Mailing Address - State:MA
Mailing Address - Zip Code:02653-3307
Mailing Address - Country:US
Mailing Address - Phone:508-255-0016
Mailing Address - Fax:
Practice Address - Street 1:70 ROUTE 28
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653-3307
Practice Address - Country:US
Practice Address - Phone:508-255-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10230431041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool