Provider Demographics
NPI:1598206237
Name:DURGIN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DURGIN
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 1:56 WAREHAM LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:EAST WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02538-1429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 WAREHAM LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:EAST WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02538-1429
Practice Address - Country:US
Practice Address - Phone:508-878-0835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1405103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10300000XOtherLABA