Provider Demographics
NPI:1881935658
Name:ROONEY-DECORPO, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ROONEY-DECORPO
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 1:205 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1406
Mailing Address - Country:US
Mailing Address - Phone:781-761-5165
Mailing Address - Fax:
Practice Address - Street 1:205 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1406
Practice Address - Country:US
Practice Address - Phone:781-761-5165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-11-9436103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303287OtherMBHP
MA1303287Medicaid
MA0000023532OtherBMC
MA99618201OtherNETWORK HEALTH
MAM18633OtherBCBS
MA1004745OtherNHP
MA042611055OtherTAX ID