Provider Demographics
NPI:1568908002
Name:BEAULIEU, JACQUELINE DE CORMIER
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DE CORMIER
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NOELLE
Other - Last Name:DE CORMIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 VFW PKWY
Mailing Address - Street 2:MAIL STOP A-122
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4927
Mailing Address - Country:US
Mailing Address - Phone:857-203-5176
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:MAIL STOP A-122
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:857-203-5176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222460104100000X
MA1165096104100000X
MA1221391041C0700X, 104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical