Provider Demographics
NPI:1457623621
Name:DAVIS, JACQUELINE A (LICSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PRINCESS LN
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1279
Mailing Address - Country:US
Mailing Address - Phone:774-381-1055
Mailing Address - Fax:877-308-2202
Practice Address - Street 1:1029 PLEASANT ST STE 101
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-2473
Practice Address - Country:US
Practice Address - Phone:844-946-2152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110796101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health