Healthcare Provider Details

I. General information

NPI: 1174898837
Provider Name (Legal Business Name): JESSICA PAGAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 PAGE ST
STOUGHTON MA
02072-6003
US

IV. Provider business mailing address

859 WILLARD ST
QUINCY MA
02169-7482
US

V. Phone/Fax

Practice location:
  • Phone: 617-334-3663
  • Fax: 617-553-9583
Mailing address:
  • Phone: 617-847-1950
  • Fax: 617-774-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121907
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: