Provider Demographics
NPI:1750697538
Name:BAXENDALE, JENNIFER MACLEOD (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MACLEOD
Last Name:BAXENDALE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BAXENDALE
Other - Last Name:LALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 EAST STREET
Mailing Address - Street 2:BRIEN CENTER
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6278
Mailing Address - Country:US
Mailing Address - Phone:413-629-1086
Mailing Address - Fax:413-448-2198
Practice Address - Street 1:1 FENN ST
Practice Address - Street 2:ADMINISTRATIVE OFFICES
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6278
Practice Address - Country:US
Practice Address - Phone:413-629-1262
Practice Address - Fax:413-448-2198
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1214001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1750697538Medicaid