Basic Information
| Provider Information | |||||||||
| NPI: | 1750697538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXENDALE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MACLEOD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LALLY | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | BAXENDALE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 333 EAST STREET | ||||||||
| Address2: | BRIEN CENTER | ||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012016278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136291086 | ||||||||
| FaxNumber: | 4134482198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 FENN ST | ||||||||
| Address2: | ADMINISTRATIVE OFFICES | ||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012016278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136291262 | ||||||||
| FaxNumber: | 4134482198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2010 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 121400 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1750697538 | 05 | MA | MEDICAID |