Provider Demographics
NPI:1487416780
Name:DAVENPORT, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 473
Mailing Address - Street 2:
Mailing Address - City:SOUTH EGREMONT
Mailing Address - State:MA
Mailing Address - Zip Code:01258-0473
Mailing Address - Country:US
Mailing Address - Phone:203-300-4633
Mailing Address - Fax:
Practice Address - Street 1:291 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1608
Practice Address - Country:US
Practice Address - Phone:413-274-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230110101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health