Provider Demographics
NPI:1346722691
Name:MAST, JENNIFER LONDON
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LONDON
Last Name:MAST
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 1:26 KETTELL PLAIN RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:MA
Mailing Address - Zip Code:01775-1248
Mailing Address - Country:US
Mailing Address - Phone:617-501-6139
Mailing Address - Fax:
Practice Address - Street 1:26 KETTELL PLAIN RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:MA
Practice Address - Zip Code:01775-1248
Practice Address - Country:US
Practice Address - Phone:617-501-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111896-SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111896OtherPAY OUT OF POCKET