Healthcare Provider Details

I. General information

NPI: 1922589837
Provider Name (Legal Business Name): JESSIE MOYNIHAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 HARRISON AVE
BOSTON MA
02118-2420
US

IV. Provider business mailing address

178 TREMONT ST
BOSTON MA
02111-1006
US

V. Phone/Fax

Practice location:
  • Phone: 617-426-2855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number110839-SW-LICSW
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: