Provider Demographics
NPI:1942010988
Name:POLANCO, JADDIEL
Entity type:Individual
Prefix:
First Name:JADDIEL
Middle Name:
Last Name:POLANCO
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 1:11 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2719
Mailing Address - Country:US
Mailing Address - Phone:978-409-7607
Mailing Address - Fax:
Practice Address - Street 1:11 ALBION ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2719
Practice Address - Country:US
Practice Address - Phone:978-409-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst