Provider Demographics
NPI:1750650487
Name:SULLIVAN-BRUNAULT, JENNIFER MARIE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:SULLIVAN-BRUNAULT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:335 WALNUT ST. EXTENSION, SUITE 200
Mailing Address - Street 2:AGAWAM PROFESSIONAL CENTER
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-1524
Mailing Address - Country:US
Mailing Address - Phone:413-789-8955
Mailing Address - Fax:413-789-0557
Practice Address - Street 1:335 WALNUT ST. EXTENSION, SUITE 200
Practice Address - Street 2:AGAWAM PROFESSIONAL CENTER
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-1524
Practice Address - Country:US
Practice Address - Phone:413-789-8955
Practice Address - Fax:413-789-0557
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1131951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical