Healthcare Provider Details

I. General information

NPI: 1093966624
Provider Name (Legal Business Name): KERRIE JONGENEELEN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MUZZEY ST STE 202A
LEXINGTON MA
02421-5211
US

IV. Provider business mailing address

19 MUZZEY ST STE 202A
LEXINGTON MA
02421-5211
US

V. Phone/Fax

Practice location:
  • Phone: 617-372-5653
  • Fax:
Mailing address:
  • Phone: 617-372-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number10646
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: