Provider Demographics
NPI:1528616398
Name:MANGIAMELI, JESSICA LYNNE (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNNE
Last Name:MANGIAMELI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TACOMA ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3516
Mailing Address - Country:US
Mailing Address - Phone:845-282-5154
Mailing Address - Fax:
Practice Address - Street 1:19 TACOMA ST # 2
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3516
Practice Address - Country:US
Practice Address - Phone:845-282-5154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2273211041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical