Provider Demographics
NPI:1205142098
Name:HANSEN, JENNIFER CAROL (BA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAROL
Last Name:HANSEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 WALTHAM ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8033
Mailing Address - Country:US
Mailing Address - Phone:781-761-5125
Mailing Address - Fax:781-863-7241
Practice Address - Street 1:1040 WALTHAM ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-8033
Practice Address - Country:US
Practice Address - Phone:781-761-5125
Practice Address - Fax:781-863-7241
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1004745OtherNHP
MA000023532OtherBMC
MA1303287OtherMBHP
MA1303287Medicaid
MAM18633OtherBCBS
MA99618201OtherNETWORK HEALTH
MA042611055OtherTAX ID
MA1303287OtherMBHP