Provider Demographics
NPI:1508952656
Name:WOODSIDE, JACKIE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:
Last Name:WOODSIDE
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 1:133 E MAIN ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-1449
Mailing Address - Country:US
Mailing Address - Phone:508-616-9555
Mailing Address - Fax:508-616-2958
Practice Address - Street 1:133 E MAIN ST
Practice Address - Street 2:SUITE #3
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1449
Practice Address - Country:US
Practice Address - Phone:508-616-9555
Practice Address - Fax:508-616-2958
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020210104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical