Provider Demographics
NPI:1245687508
Name:GUSTAFSON, JESSICA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 WHITFORD CIR
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02050-4148
Mailing Address - Country:US
Mailing Address - Phone:617-750-9769
Mailing Address - Fax:
Practice Address - Street 1:77 ACCORD PARK DR # D-5
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1623
Practice Address - Country:US
Practice Address - Phone:857-307-6399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA13071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health