Provider Demographics
NPI:1609349711
Name:ST PIERRE, JADE KIMBERLY
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:KIMBERLY
Last Name:ST PIERRE
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 1:161 BARLOW ST APT 1
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02723-3772
Mailing Address - Country:US
Mailing Address - Phone:774-444-3062
Mailing Address - Fax:
Practice Address - Street 1:657 QUARRY ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1020
Practice Address - Country:US
Practice Address - Phone:508-997-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAC00158004OtherMASS HEALTH CONNECTOR
MAMTN964219079OtherBCBS