Provider Demographics
NPI:1679575732
Name:FEMINO-NICOLL, JACQUELINE (LICSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FEMINO-NICOLL
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 1:28 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01951-1721
Mailing Address - Country:US
Mailing Address - Phone:978-463-0463
Mailing Address - Fax:978-499-2177
Practice Address - Street 1:28 GREEN ST
Practice Address - Street 2:
Practice Address - City:NEWBURY
Practice Address - State:MA
Practice Address - Zip Code:01951-1721
Practice Address - Country:US
Practice Address - Phone:978-463-0463
Practice Address - Fax:978-499-2177
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10265411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P22923Medicare ID - Type Unspecified