Provider Demographics
NPI:1558739177
Name:DWELLEY, JADE
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:DWELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3409
Mailing Address - Country:US
Mailing Address - Phone:334-663-5505
Mailing Address - Fax:
Practice Address - Street 1:10 GUEST ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2066
Practice Address - Country:US
Practice Address - Phone:334-663-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500822481041C0700X, 1041S0200X
390200000X
MA1218671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program