Healthcare Provider Details

I. General information

NPI: 1134464019
Provider Name (Legal Business Name): JENNIFER CHISHOLM LICSW, MLADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 CHESTNUT ST
MANCHESTER NH
03101-1804
US

IV. Provider business mailing address

464 CHESTNUT ST
MANCHESTER NH
03101-1804
US

V. Phone/Fax

Practice location:
  • Phone: 603-518-4325
  • Fax: 603-668-6260
Mailing address:
  • Phone: 603-518-4325
  • Fax: 603-668-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0887
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1788
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: