Basic Information
| Provider Information | |||||||||
| NPI: | 1467588277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALEM-RUSSO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 795 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027211733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086745600 | ||||||||
| FaxNumber: | 5082355009 | ||||||||
| Practice Location | |||||||||
| Address1: | 795 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027211733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086745600 | ||||||||
| FaxNumber: | 5082355009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 111118 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1306715 | 05 | MA | MEDICAID |