Provider Demographics
NPI:1497076657
Name:SERVELLO, JEAN (MA CLINICAL PSYCHE)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:SERVELLO
Suffix:
Gender:F
Credentials:MA CLINICAL PSYCHE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HAWTHORNE CIR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-2816
Mailing Address - Country:US
Mailing Address - Phone:978-475-3506
Mailing Address - Fax:978-475-3506
Practice Address - Street 1:1 HAWTHORNE CIR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-2816
Practice Address - Country:US
Practice Address - Phone:978-475-3506
Practice Address - Fax:978-475-3506
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA447106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist