Provider Demographics
NPI:1508454570
Name:BURGOS, JESSICA MONIN (BA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MONIN
Last Name:BURGOS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MONIN
Other - Last Name:LUCIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JESSICA MLUCIANO
Mailing Address - Street 1:120 BURNCOAT ST # 1
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1333
Mailing Address - Country:US
Mailing Address - Phone:508-933-4572
Mailing Address - Fax:
Practice Address - Street 1:11 SYCAMORE ST # 1
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-2213
Practice Address - Country:US
Practice Address - Phone:508-933-4572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAFD8ED938-F469-49E8-9Medicaid