Provider Demographics
NPI:1316411770
Name:PROVENZANO, JACQUELINE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PROVENZANO
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 1:218 LITTLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COTUIT
Mailing Address - State:MA
Mailing Address - Zip Code:02635-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1185 FALMOUTH RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02632-3066
Practice Address - Country:US
Practice Address - Phone:508-862-9929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000224420104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker