Provider Demographics
NPI:1215333109
Name:MASSIE, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MASSIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 DAVIS ST
Mailing Address - Street 2:#100
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2757
Mailing Address - Country:US
Mailing Address - Phone:510-618-6174
Mailing Address - Fax:
Practice Address - Street 1:500 DAVIS ST
Practice Address - Street 2:#100
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-2757
Practice Address - Country:US
Practice Address - Phone:510-618-6174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60513104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker