Provider Demographics
NPI:1013513209
Name:DOE, JACQUELINE C (LICSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:DOE
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 1:165 MAIN ST UNIT 213
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1584
Mailing Address - Country:US
Mailing Address - Phone:508-216-0331
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST UNIT 213
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1584
Practice Address - Country:US
Practice Address - Phone:508-216-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1217551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical