Provider Demographics
NPI:1790502920
Name:ZELLE, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:ZELLE
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 1:416 COMMONWEALTH AVE APT 418
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-2812
Mailing Address - Country:US
Mailing Address - Phone:617-869-7565
Mailing Address - Fax:
Practice Address - Street 1:416 COMMONWEALTH AVE APT 418
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2812
Practice Address - Country:US
Practice Address - Phone:617-869-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2287951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical