Provider Demographics
NPI:1336747435
Name:ALSTON, JACKLINE
Entity Type:Individual
Prefix:
First Name:JACKLINE
Middle Name:
Last Name:ALSTON
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 1:50 LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-6311
Mailing Address - Country:US
Mailing Address - Phone:857-266-8036
Mailing Address - Fax:617-600-4728
Practice Address - Street 1:50 LEBANON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-6311
Practice Address - Country:US
Practice Address - Phone:857-266-8036
Practice Address - Fax:617-600-4728
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASA0950118101Y00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001385522OtherSTATE