Basic Information
| Provider Information | |||||||||
| NPI: | 1588863732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAURIE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S.W LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172543800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | FRANCISCAN HOSPITAL FOR CHILDREN | ||||||||
| Address2: | 30 WARREN STREET | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172543800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 114009 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.