Provider Demographics
NPI:1659632008
Name:SHEA, JACQUELINE A
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:SHEA
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 1:687 HIGHLAND AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2232
Mailing Address - Country:US
Mailing Address - Phone:800-455-8726
Mailing Address - Fax:866-455-8839
Practice Address - Street 1:687 HIGHLAND AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2232
Practice Address - Country:US
Practice Address - Phone:800-455-8726
Practice Address - Fax:866-455-8839
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2439101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)