Healthcare Provider Details

I. General information

NPI: 1174872147
Provider Name (Legal Business Name): MS. JEANNIE MARIE BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 WARREN ST
ROXBURY MA
02119-1833
US

IV. Provider business mailing address

637 WASHINGTON ST
DORCHESTER MA
02124-3510
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-7400
  • Fax:
Mailing address:
  • Phone: 617-825-9660
  • Fax: 617-288-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119874
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: