Provider Demographics
NPI:1255759932
Name:SANDBERG, JENNIE (MED)
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MS
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:SAISAKORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:528 GREAT ELM WAY
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01718-1005
Mailing Address - Country:US
Mailing Address - Phone:508-494-5658
Mailing Address - Fax:
Practice Address - Street 1:315 LITTLETON RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3311
Practice Address - Country:US
Practice Address - Phone:781-281-7601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2255103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst