Provider Demographics
NPI:1306345483
Name:INTERNICOLA, JEANNE MARY
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:MARY
Last Name:INTERNICOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-3063
Mailing Address - Country:US
Mailing Address - Phone:617-268-5000
Mailing Address - Fax:
Practice Address - Street 1:210 OLD COLONY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2413
Practice Address - Country:US
Practice Address - Phone:617-268-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1915101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043220123Medicaid