Provider Demographics
NPI:1639164627
Name:REUSSER, JONATHAN W (LICSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:REUSSER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BEDFORD ST
Mailing Address - Street 2:SUITE 25
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4646
Mailing Address - Country:US
Mailing Address - Phone:781-861-1879
Mailing Address - Fax:781-861-1879
Practice Address - Street 1:76 BEDFORD ST
Practice Address - Street 2:SUITE 25
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4646
Practice Address - Country:US
Practice Address - Phone:781-861-1879
Practice Address - Fax:781-861-1879
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARE P21397Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO