Provider Demographics
NPI:1780191726
Name:JESSICA PRODIS LICSW
Entity type:Organization
Organization Name:JESSICA PRODIS LICSW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:PRODIS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:413-687-8239
Mailing Address - Street 1:30 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-1813
Practice Address - Country:US
Practice Address - Phone:413-687-8239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-29
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1184951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty