Healthcare Provider Details

I. General information

NPI: 1992944953
Provider Name (Legal Business Name): JACQUELINE ELAINE DUFAULT LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE DUFAULT RN

II. Dates (important events)

Enumeration Date: 02/16/2009
Last Update Date: 02/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 DOGWOOD DR
FORESTDALE MA
02644-1208
US

IV. Provider business mailing address

33 DOGWOOD DR
FORESTDALE MA
02644-1208
US

V. Phone/Fax

Practice location:
  • Phone: 508-477-3230
  • Fax:
Mailing address:
  • Phone: 508-477-3230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number213414
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: