Provider Demographics
NPI:1467295972
Name:MIS, JENNIFER LAUREN (MA INTERN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAUREN
Last Name:MIS
Suffix:
Gender:F
Credentials:MA INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 SUMMER ST STE 145A
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-0200
Mailing Address - Country:US
Mailing Address - Phone:978-309-1902
Mailing Address - Fax:978-268-5768
Practice Address - Street 1:76 SUMMER ST STE 145A
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-0200
Practice Address - Country:US
Practice Address - Phone:978-309-1902
Practice Address - Fax:978-268-5768
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor