Provider Demographics
NPI:1609064229
Name:DAUM, JENNA (MED)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DAUM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:DAUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:497 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02746-2420
Mailing Address - Country:US
Mailing Address - Phone:508-991-7487
Mailing Address - Fax:508-997-2677
Practice Address - Street 1:497 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02746-2420
Practice Address - Country:US
Practice Address - Phone:508-991-7487
Practice Address - Fax:508-997-2677
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1894234Medicaid