Healthcare Provider Details

I. General information

NPI: 1609183888
Provider Name (Legal Business Name): JESSICA DAWN GLEASON ED.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WARREN ST
BOSTON MA
02135-3602
US

IV. Provider business mailing address

30 WARREN ST
BOSTON MA
02135-3602
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-3800
  • Fax:
Mailing address:
  • Phone: 617-254-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: