Provider Demographics
NPI:1093212409
Name:PESTANA, JENNIFER LYNN (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PESTANA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 SHAWSHEEN ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-2336
Mailing Address - Country:US
Mailing Address - Phone:978-851-2544
Mailing Address - Fax:
Practice Address - Street 1:TEWKSBURY HOSPITAL
Practice Address - Street 2:365 EAST ST.
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876
Practice Address - Country:US
Practice Address - Phone:978-851-7321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1110331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical