Provider Demographics
NPI:1497786271
Name:MARCIELLO, JILL ANN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ANN
Last Name:MARCIELLO
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 1:115 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:508-894-8339
Mailing Address - Fax:508-894-8334
Practice Address - Street 1:MCLEAN HOSPITAL SOUTHEAST LOCATION
Practice Address - Street 2:940 BELMONT STREET
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-894-8339
Practice Address - Fax:508-894-8334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10277971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP21121Medicare ID - Type Unspecified