Provider Demographics
NPI:1881722478
Name:DERMARDEROSIAN, JENNIFER (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DERMARDEROSIAN
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 1:21 GOULD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1250
Mailing Address - Country:US
Mailing Address - Phone:781-844-8624
Mailing Address - Fax:
Practice Address - Street 1:4 MUZZEY ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5220
Practice Address - Country:US
Practice Address - Phone:781-844-8624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10257411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical