Healthcare Provider Details

I. General information

NPI: 1679054621
Provider Name (Legal Business Name): JENNIFER MCCLINTOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 QUEEN ST STE 13
WORCESTER MA
01610-2478
US

IV. Provider business mailing address

26 QUEEN ST STE 13
WORCESTER MA
01610-2478
US

V. Phone/Fax

Practice location:
  • Phone: 508-754-2860
  • Fax:
Mailing address:
  • Phone: 508-754-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122262
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number221805
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: