Healthcare Provider Details

I. General information

NPI: 1962500744
Provider Name (Legal Business Name): DAPHNE LYNN JAKSTIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3088 CRANBERRY HWY
EAST WAREHAM MA
02538-4800
US

IV. Provider business mailing address

48 S FRANKLIN ST
DALLASTOWN PA
17313-2006
US

V. Phone/Fax

Practice location:
  • Phone: 508-295-7990
  • Fax: 508-295-3781
Mailing address:
  • Phone: 508-274-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112160
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW018583
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: