Provider Demographics
NPI:1700322278
Name:SCULLY, JONATHAN (MA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SCULLY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SCHOOL ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2781
Mailing Address - Country:US
Mailing Address - Phone:978-632-9400
Mailing Address - Fax:978-632-6524
Practice Address - Street 1:205 SCHOOL ST
Practice Address - Street 2:SUITE 301
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-2781
Practice Address - Country:US
Practice Address - Phone:978-632-9400
Practice Address - Fax:978-632-6524
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042206041Medicaid