Basic Information
| Provider Information | |||||||||
| NPI: | 1619027091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADAMS | ||||||||
| FirstName: | JEANNINE | ||||||||
| MiddleName: | BRETON | ||||||||
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| OtherLastName: | BRETON | ||||||||
| OtherFirstName: | JEANNINE | ||||||||
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| OtherCredential: | MSW, LICSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 77 RUMFORD AVE | ||||||||
| Address2: | CHILDREN'S CHARTER DIV. OF KEY PROGRAM, INC. | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024533872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818944307 | ||||||||
| FaxNumber: | 7818941195 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 RUMFORD AVE | ||||||||
| Address2: | CHILDREN'S CHARTER DIV. OF KEY PROGRAM, INC. | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024533872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818944307 | ||||||||
| FaxNumber: | 7818941195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1017026 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.