Provider Demographics
NPI:1568530830
Name:WILLIS, JANE MARY (LICSW)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:MARY
Last Name:WILLIS
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 1:100 LAFAYETTE ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-6008
Mailing Address - Country:US
Mailing Address - Phone:401-722-9091
Mailing Address - Fax:401-722-5451
Practice Address - Street 1:100 LAFAYETTE ST
Practice Address - Street 2:SUITE 305
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-6008
Practice Address - Country:US
Practice Address - Phone:401-722-9091
Practice Address - Fax:401-722-5451
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW003531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical