Provider Demographics
NPI:1639320013
Name:ETUE, JENNIFER M (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:ETUE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-444-0400
Mailing Address - Fax:401-444-0468
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-274-6339
Practice Address - Fax:401-453-6290
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW020151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJE72997Medicaid
1021740OtherNHP/BEACON GROUP