Provider Demographics
NPI:1851751267
Name:REYNOSO, JEANETTE (LSW)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137B LUCERNE ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3923
Mailing Address - Country:US
Mailing Address - Phone:617-849-1560
Mailing Address - Fax:
Practice Address - Street 1:434 WARREN ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02121-1325
Practice Address - Country:US
Practice Address - Phone:617-989-0292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health