Provider Demographics
NPI:1699257022
Name:FAVREAU, JENNIFER WALSH (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WALSH
Last Name:FAVREAU
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 PRINCETON BLVD. APT. 22
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 PRINCETON BLVD. APT. 22
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851
Practice Address - Country:US
Practice Address - Phone:978-505-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-01
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1160091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical