MEDICARE: JEANNETTE MENDEZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW02815	RI

General Provider Information

NPI Number	:	1184349805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNETTE MENDEZ LCSW

Provider Business Mailing Address
First Line	:	PO BOX 27732
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02907-0558
Country	:	US
Telephone Number	:	401-999-2809
Fax Number	:

Provider Business Practice Location Address
First Line	:	153 LEDGE ST
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02904-1532
Country	:	US
Telephone Number	:	401-999-2809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2022
Last Update Date	:	10/05/2022

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