Provider Demographics
NPI:1336606946
Name:INNOPSYCH, INC.
Entity Type:Organization
Organization Name:INNOPSYCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARMAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-803-2417
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02471-0894
Mailing Address - Country:US
Mailing Address - Phone:617-803-2417
Mailing Address - Fax:617-500-9710
Practice Address - Street 1:40 SPRING ST STE 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3476
Practice Address - Country:US
Practice Address - Phone:617-803-2417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA70010000W06742OtherBCBS