Provider Demographics
NPI:1417416801
Name:KANACH, JESSICA MARY MICHELE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARY MICHELE
Last Name:KANACH
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 1:29 MARION ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-3131
Mailing Address - Country:US
Mailing Address - Phone:617-590-0059
Mailing Address - Fax:
Practice Address - Street 1:29 MARION ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-3131
Practice Address - Country:US
Practice Address - Phone:617-590-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician