Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 104100000X | Social Worker | 120046 | MA |
Y | 1041C0700X | Clinical Social Worker | 120046 | MA |
NPI | 1003329095 |
---|---|
Provider Name | Ms. Jacqueline Bango |
First Address | Boston, MA 02113-1638 |
Second Address | Boston, MA 02114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2017 |
Last Update Date | 13/11/2017 |