Provider Demographics
NPI:1053370080
Name:MIRANDA, JACQUELINE (LICSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1277 COMMONWEALTH AVE
Mailing Address - Street 2:UNIT #203
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-3527
Mailing Address - Country:US
Mailing Address - Phone:617-787-0342
Mailing Address - Fax:
Practice Address - Street 1:333 LONGWOOD AVE
Practice Address - Street 2:FLOOR 6
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5711
Practice Address - Country:US
Practice Address - Phone:617-355-5250
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10262841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical