Healthcare Provider Details

I. General information

NPI: 1902896491
Provider Name (Legal Business Name): JASSY TIMBERLAKE M.ED., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MAIN ST SUITE 103
FLORENCE MA
01062-1492
US

IV. Provider business mailing address

40 MAIN ST SUIE 103
FLORENCE MA
01062-1492
US

V. Phone/Fax

Practice location:
  • Phone: 413-587-0095
  • Fax:
Mailing address:
  • Phone: 413-587-0095
  • Fax: 413-587-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1259
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: