Provider Demographics
NPI:1497825889
Name:EDGE, JENNIFER L (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:EDGE
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 1:1090 CRANSTON ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-7323
Mailing Address - Country:US
Mailing Address - Phone:401-467-9610
Mailing Address - Fax:401-223-0121
Practice Address - Street 1:1090 CRANSTON ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-7323
Practice Address - Country:US
Practice Address - Phone:401-467-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW028651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146467OtherANTHEM BCBS