Provider Demographics
NPI:1962422345
Name:SPEAKS, JENNIFER DWYER (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DWYER
Last Name:SPEAKS
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 1:18 LEE RD
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-4070
Mailing Address - Country:US
Mailing Address - Phone:401-871-7009
Mailing Address - Fax:
Practice Address - Street 1:542 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-1947
Practice Address - Country:US
Practice Address - Phone:401-871-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
RICSW013511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412296OtherEI BLUE CHIP
RI6400144OtherEI UHP
RI2092OtherEI NHPRC
RI292177OtherEI BLUE CROSS
RIES01788Medicaid