Healthcare Provider Details

I. General information

NPI: 1255005484
Provider Name (Legal Business Name): JASMINE WITKOWSKI, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 RIVERSIDE DR
PEMBROKE MA
02359-4947
US

IV. Provider business mailing address

3 BRIAR PATH WAY
CARVER MA
02330-1350
US

V. Phone/Fax

Practice location:
  • Phone: 774-766-7986
  • Fax:
Mailing address:
  • Phone: 774-766-7986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JASMINE N WITKOWSKI
Title or Position: PRESIDENT
Credential: LICSW
Phone: 774-766-7986