Provider Demographics
NPI:1568639375
Name:VENEZIA PHILLIPS, JO-ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:JO-ANN
Middle Name:
Last Name:VENEZIA PHILLIPS
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 1:165 MAIN ST UNIT 205
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1584
Mailing Address - Country:US
Mailing Address - Phone:978-304-9283
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST UNIT 205
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1584
Practice Address - Country:US
Practice Address - Phone:978-304-9283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA1162311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA116231OtherMASSACHUSETTS STATE LICENSING BOARD OF SOCIAL WORKERS