Provider Demographics
NPI:1689672123
Name:BRELSFORD, JENNIFER R (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:BRELSFORD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:BRELSFORD LICSW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:418 SOUTHAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-9763
Mailing Address - Country:US
Mailing Address - Phone:413-538-9579
Mailing Address - Fax:
Practice Address - Street 1:121 MAIN ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-2075
Practice Address - Country:US
Practice Address - Phone:413-527-8903
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10277521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABR P 21139Medicare ID - Type UnspecifiedLICSW