Provider Demographics
NPI:1992863377
Name:PAUL, CLANCEY JACKSON (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CLANCEY
Middle Name:JACKSON
Last Name:PAUL
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 1:2 PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-6228
Mailing Address - Country:US
Mailing Address - Phone:603-247-0386
Mailing Address - Fax:
Practice Address - Street 1:16 CLARKE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4988
Practice Address - Country:US
Practice Address - Phone:781-402-2442
Practice Address - Fax:781-402-1744
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1132471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical