Provider Demographics
NPI:1528612389
Name:MIRABELLA, JENNIFER A (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MIRABELLA
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 1:74 FARQUHAR ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1405
Mailing Address - Country:US
Mailing Address - Phone:617-968-8211
Mailing Address - Fax:781-461-2585
Practice Address - Street 1:456 PROVIDENCE HWY
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6815
Practice Address - Country:US
Practice Address - Phone:781-752-8774
Practice Address - Fax:781-461-2585
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2220291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical