Basic Information
| Provider Information | |||||||||
| NPI: | 1033545470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNE | ||||||||
| FirstName: | DAWNA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 MYSTIC AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021554632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813961199 | ||||||||
| FaxNumber: | 7813961439 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 MYSTIC AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021554632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813961199 | ||||||||
| FaxNumber: | 7813961439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 204888 | MA | N | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | 99 | MA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.