Provider Demographics
NPI:1124491089
Name:JACO O'BRIEN, SANDRA PATRICIA (LICSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:PATRICIA
Last Name:JACO O'BRIEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:PATRICIA
Other - Last Name:JACO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-0554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:537 KING ST FL 2
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1211
Practice Address - Country:US
Practice Address - Phone:978-649-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10276301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical