Healthcare Provider Details

I. General information

NPI: 1952566002
Provider Name (Legal Business Name): JILL MICHELLE ROFFMAN LEVINE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL M LEVINE LICSW

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 BOSTON ST
LYNN MA
01904
US

IV. Provider business mailing address

29 MANTON RD
SWAMPSCOTT MA
01907-1528
US

V. Phone/Fax

Practice location:
  • Phone: 978-750-6828
  • Fax:
Mailing address:
  • Phone: 339-440-0056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1025193
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: