Provider Demographics
NPI:1144274978
Name:GARDNER, JENNIFER (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GARDNER
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 1:22 WOBURN ST
Mailing Address - Street 2:SUITE 36
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-3026
Mailing Address - Country:US
Mailing Address - Phone:781-944-7700
Mailing Address - Fax:781-944-7711
Practice Address - Street 1:22 WOBURN ST
Practice Address - Street 2:SUITE 36
Practice Address - City:READING
Practice Address - State:MA
Practice Address - Zip Code:01867-3026
Practice Address - Country:US
Practice Address - Phone:781-944-7700
Practice Address - Fax:781-944-7711
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10304661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23673Medicare ID - Type Unspecified