Provider Demographics
NPI:1316484298
Name:MKPANAM, JESSICA (MSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MKPANAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 FATHER DEVALLES BLVD STE 15
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1519
Practice Address - Country:US
Practice Address - Phone:978-408-6446
Practice Address - Fax:508-567-3309
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1279771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical