MEDICARE: JACQUELYN MACDOUGALL LMHC

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	101YM0800X	Mental Health Counselor	11654	MA

General Provider Information

NPI Number	:	1558981928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN MACDOUGALL LMHC

Provider Business Mailing Address
First Line	:	37 HOWELL ST APT 3
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02125-1150
Country	:	US
Telephone Number	:	781-424-6422
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 WALNUT ST STE 32
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02461-1271
Country	:	US
Telephone Number	:	781-423-3523
Fax Number	:

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

Provider Enumeration Date	:	04/25/2020
Last Update Date	:	04/25/2020

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