Provider Demographics
NPI:1184107450
Name:FORTIN, JESSICA ELIZABETH (LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:FORTIN
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 1:1 ADMINISTRATION RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-3230
Mailing Address - Country:US
Mailing Address - Phone:508-614-5206
Mailing Address - Fax:
Practice Address - Street 1:1 ADMINISTRATION RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-3230
Practice Address - Country:US
Practice Address - Phone:508-614-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1168331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical