Healthcare Provider Details

I. General information

NPI: 1417465725
Provider Name (Legal Business Name): JESSICA CARON REYNOLDS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JESSICA CARON DANFORTH

II. Dates (important events)

Enumeration Date: 01/21/2018
Last Update Date: 01/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 SOUTH ST
WARE MA
01082-1616
US

IV. Provider business mailing address

PO BOX 234
WEST WARREN MA
01092-0234
US

V. Phone/Fax

Practice location:
  • Phone: 413-967-6241
  • Fax: 413-967-9807
Mailing address:
  • Phone: 413-351-1267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116682
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: