Provider Demographics
NPI:1679833495
Name:GOMES, JAQUELINA (BS)
Entity Type:Individual
Prefix:
First Name:JAQUELINA
Middle Name:
Last Name:GOMES
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 RAINTREE CIR APT E
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-1913
Mailing Address - Country:US
Mailing Address - Phone:774-240-3466
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-26
Last Update Date:2012-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health