Provider Demographics
NPI:1689035610
Name:APAMO-GANNON, JESCAH
Entity Type:Individual
Prefix:
First Name:JESCAH
Middle Name:
Last Name:APAMO-GANNON
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 1:86 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-3024
Mailing Address - Country:US
Mailing Address - Phone:508-340-9006
Mailing Address - Fax:
Practice Address - Street 1:86 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-3024
Practice Address - Country:US
Practice Address - Phone:508-340-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0416103K00000X
MA11314663103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst