Healthcare Provider Details

I. General information

NPI: 1396231130
Provider Name (Legal Business Name): JESSICA LEE GWINN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 03/09/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WILLOW ST
YARMOUTH PORT MA
02675-1770
US

IV. Provider business mailing address

221 WILLOW ST
SOUTH YARMOUTH MA
02664-3726
US

V. Phone/Fax

Practice location:
  • Phone: 508-737-3491
  • Fax:
Mailing address:
  • Phone: 774-212-9106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: