Provider Demographics
NPI:1992944953
Name:DUFAULT, JACQUELINE ELAINE (LICSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:DUFAULT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DUFAULT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:33 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644-1208
Mailing Address - Country:US
Mailing Address - Phone:508-477-3230
Mailing Address - Fax:
Practice Address - Street 1:33 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:FORESTDALE
Practice Address - State:MA
Practice Address - Zip Code:02644-1208
Practice Address - Country:US
Practice Address - Phone:508-477-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2134141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical