Healthcare Provider Details

I. General information

NPI: 1437872405
Provider Name (Legal Business Name): JENNIFER KASTICK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MAIN ST
BRISTOL NH
03222-3514
US

IV. Provider business mailing address

155 N MAIN ST
BRISTOL NH
03222-3514
US

V. Phone/Fax

Practice location:
  • Phone: 603-744-8162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1519
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: