Provider Demographics
NPI:1477646495
Name:FAIN, JEAN BARBARA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:BARBARA
Last Name:FAIN
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 1:298 HARRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4024
Mailing Address - Country:US
Mailing Address - Phone:978-505-7333
Mailing Address - Fax:
Practice Address - Street 1:9 DAMONMILL SQ
Practice Address - Street 2:2H-2 NORTH
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2858
Practice Address - Country:US
Practice Address - Phone:978-505-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10242931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO7281OtherBLUE CROSS BLUE SHIELD
MAFAP22660Medicare PIN