Provider Demographics
NPI:1760965479
Name:GEORGALLAS, JACQUELYN MAYO (LICSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MAYO
Last Name:GEORGALLAS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:MARY
Other - Last Name:MAYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-2855
Mailing Address - Country:US
Mailing Address - Phone:603-475-3771
Mailing Address - Fax:
Practice Address - Street 1:173 S RIVER RD STE 3
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6930
Practice Address - Country:US
Practice Address - Phone:978-934-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH29351041C0700X
MA0002240461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical