MEDICARE: JACLYN MICKIEWICZ LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	1041C0700X	Clinical Social Worker	LICSW126010	MA

General Provider Information

NPI Number	:	1295953461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN MICKIEWICZ LICSW

Provider Business Mailing Address
First Line	:	26 SEVERANCE ST
Second Line	:
City	:	SHELBURNE FALLS
State	:	MA
Zip	:	01370-1217
Country	:	US
Telephone Number	:	413-775-3432
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 SEVERANCE ST
Second Line	:
City	:	SHELBURNE FALLS
State	:	MA
Zip	:	01370-1217
Country	:	US
Telephone Number	:	413-775-3432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	10/30/2024

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