Provider Demographics
NPI:1518985407
Name:BRESHIN, JERROLD (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JERROLD
Middle Name:
Last Name:BRESHIN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TENEYCKE HILL RD
Mailing Address - Street 2:
Mailing Address - City:N FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02556-3118
Mailing Address - Country:US
Mailing Address - Phone:508-495-0554
Mailing Address - Fax:508-495-0559
Practice Address - Street 1:342 GIFFORD ST UNIT C
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-5107
Practice Address - Country:US
Practice Address - Phone:508-495-0554
Practice Address - Fax:508-495-0559
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASW1075041041C0700X
NYPR041299-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1038700OtherTRICARE
MA1896024OtherMBHP
MA1896024Medicaid
MA1854941OtherMASS HEALTH
MA2041870OtherHCVM
MAP07062OtherBCBSMA
MA1854941OtherMASS HEALTH