Provider Demographics
NPI:1346852076
Name:TIMMS, JT MICAH
Entity Type:Individual
Prefix:
First Name:JT
Middle Name:MICAH
Last Name:TIMMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:TIMMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1140 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3693
Mailing Address - Country:US
Mailing Address - Phone:617-747-6407
Mailing Address - Fax:
Practice Address - Street 1:1140 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3693
Practice Address - Country:US
Practice Address - Phone:617-747-6407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000226879104100000X
MA1271561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker