Basic Information
| Provider Information | |||||||||
| NPI: | 1952566002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROFFMAN LEVINE | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEVINE | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29 MANTON RD | ||||||||
| Address2: | |||||||||
| City: | SWAMPSCOTT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019071528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3394400056 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 162 BOSTON ST | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787506828 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1025193 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.