Provider Demographics
NPI:1184337321
Name:CARLSON, JENNIFER (PHD, LCSW, CEM)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD, LCSW, CEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 N MAIN ST UNIT 732
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-5537
Mailing Address - Country:US
Mailing Address - Phone:413-388-0475
Mailing Address - Fax:
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-1838
Practice Address - Country:US
Practice Address - Phone:508-797-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2265951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA226595Medicaid