Healthcare Provider Details

I. General information

NPI: 1679866230
Provider Name (Legal Business Name): JESSICA LEE DAGENAIS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA STEWARD

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ALLEN ST STE F
HAMPDEN MA
01036-9552
US

IV. Provider business mailing address

PO BOX 21
SOMERS CT
06071-0021
US

V. Phone/Fax

Practice location:
  • Phone: 513-817-1487
  • Fax: 860-971-3364
Mailing address:
  • Phone: 413-595-2079
  • Fax: 860-971-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8450
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: