Provider Demographics
NPI:1881806065
Name:MARK, JACLYN GILDEA (CRC)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:GILDEA
Last Name:MARK
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 COMMONWEALTH AVE.
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:617-488-5706
Mailing Address - Fax:
Practice Address - Street 1:301 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150
Practice Address - Country:US
Practice Address - Phone:617-488-5706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA00098922103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation