Healthcare Provider Details

I. General information

NPI: 1215700455
Provider Name (Legal Business Name): THAIS JARDIM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 BEDFORD ST
WHITMAN MA
02382-1820
US

IV. Provider business mailing address

29 PARK AVE
WHITMAN MA
02382-1418
US

V. Phone/Fax

Practice location:
  • Phone: 781-447-6425
  • Fax:
Mailing address:
  • Phone: 781-534-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number229264
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: