Provider Demographics
NPI:1366836306
Name:REIS-DRISCOLL, JESSICA (LICSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:REIS-DRISCOLL
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 1:873 WARWICK AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3645
Mailing Address - Country:US
Mailing Address - Phone:401-271-3689
Mailing Address - Fax:
Practice Address - Street 1:10 ELMGROVE AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4124
Practice Address - Country:US
Practice Address - Phone:401-271-3689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW01844104100000X, 1041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty