Basic Information
| Provider Information | |||||||||
| NPI: | 1770837734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 PAWTUCKET AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028603811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017224644 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Practice Location | |||||||||
| Address1: | 166 PAWTUCKET AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028603811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017224644 | ||||||||
| FaxNumber: | 4017225280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | GH56996 | 05 | RI | MEDICAID |