Provider Demographics
NPI:1679602981
Name:JENKINS, AMANDA HAZEL (LICSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:HAZEL
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BOSTON ST
Mailing Address - Street 2:2A
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-2030
Mailing Address - Country:US
Mailing Address - Phone:617-623-7752
Mailing Address - Fax:
Practice Address - Street 1:12 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905-2820
Practice Address - Country:US
Practice Address - Phone:781-593-9692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1118951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical