Provider Demographics
NPI:1023783107
Name:ARDERY, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:ARDERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MCLEAN HOSPITAL, APPLETON HOUSE
Mailing Address - Street 2:115 MILL ST
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1064
Mailing Address - Country:US
Mailing Address - Phone:617-855-3121
Mailing Address - Fax:
Practice Address - Street 1:APPLETON HOUSE
Practice Address - Street 2:115 MILL ST
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1064
Practice Address - Country:US
Practice Address - Phone:617-855-3121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228137104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker