Provider Demographics
NPI:1477542777
Name:GOLDSTEIN, JESSICA ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ELLEN
Other - Last Name:KELLSTEIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1041
Mailing Address - Country:US
Mailing Address - Phone:617-855-2206
Mailing Address - Fax:617-855-3691
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1041
Practice Address - Country:US
Practice Address - Phone:617-855-2206
Practice Address - Fax:617-855-3691
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7707103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05983OtherBLUE CROSS/BLUE SHIELD
MAW05983OtherBLUE CROSS/BLUE SHIELD