Provider Demographics
NPI:1811753981
Name:JACQUES-SIMON, ANAYA
Entity type:Individual
Prefix:
First Name:ANAYA
Middle Name:
Last Name:JACQUES-SIMON
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 1:18 LIGHT GUARD DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5704
Mailing Address - Country:US
Mailing Address - Phone:781-866-3962
Mailing Address - Fax:
Practice Address - Street 1:376 HALE ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2098
Practice Address - Country:US
Practice Address - Phone:781-866-3962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician