Provider Demographics
NPI:1174764955
Name:TISDALE, JACQUELINE M (MA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TUPPERWARE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-6815
Mailing Address - Country:US
Mailing Address - Phone:781-437-1323
Mailing Address - Fax:
Practice Address - Street 1:178 PINE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2312
Practice Address - Country:US
Practice Address - Phone:781-437-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA685661OtherTUFTS
MA1312677Medicaid
MA1312677Medicaid