Provider Demographics
NPI:1366851693
Name:ST VAL, JEAN (LGSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:ST VAL
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-2446
Mailing Address - Country:US
Mailing Address - Phone:410-228-3929
Mailing Address - Fax:
Practice Address - Street 1:426 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2446
Practice Address - Country:US
Practice Address - Phone:410-228-3929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG07869104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker