Basic Information
Provider Information | |||||||||
NPI: | 1730413725 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRANT | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NEAGLE-GILLON | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 31 COUNTY ST | ||||||||
Address2: |   | ||||||||
City: | DEDHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 020264107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 130 CONDOR ST | ||||||||
Address2: |   | ||||||||
City: | EAST BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021281305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6175696560 | ||||||||
FaxNumber: | 6175691856 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2009 | ||||||||
LastUpdateDate: | 03/27/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.