Basic Information
| Provider Information | |||||||||
| NPI: | 1407464076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAGNE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 COVE ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027201357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086780041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 126 COVE ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027201357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086780041 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 10/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1 | 01 | N/A | OTHER |