Provider Demographics
NPI:1790900397
Name:MARTINO, JACQUELINE (LICSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:10 CARDINAL ROAD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602
Mailing Address - Country:US
Mailing Address - Phone:508-791-8243
Mailing Address - Fax:508-519-5373
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0096
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1102031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical