Provider Demographics
NPI:1104898147
Name:OSHLAG, JORDAN A (MSW)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:A
Last Name:OSHLAG
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 JAQUES AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2476
Mailing Address - Country:US
Mailing Address - Phone:508-860-1163
Mailing Address - Fax:508-860-1115
Practice Address - Street 1:72 JAQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-860-1163
Practice Address - Fax:508-860-1115
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10193571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM20784Medicare PIN