Provider Demographics
NPI:1730103284
Name:HARPER, MARY JILL (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY JILL
Middle Name:
Last Name:HARPER
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 1:128 CRAFTS RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1826
Mailing Address - Country:US
Mailing Address - Phone:617-738-1241
Mailing Address - Fax:617-738-1241
Practice Address - Street 1:26 CITY HALL MALL
Practice Address - Street 2:HARVARD VANGUARD MEDICAL ASSOCIATES
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4754
Practice Address - Country:US
Practice Address - Phone:781-306-5463
Practice Address - Fax:781-306-5015
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1025111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21007Medicare ID - Type Unspecified