Provider Demographics
NPI:1437817269
Name:PUCHALSKY, JASON (LICSW)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PUCHALSKY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WARDS RAVINE WAY
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-9398
Mailing Address - Country:US
Mailing Address - Phone:908-670-5843
Mailing Address - Fax:
Practice Address - Street 1:1881 WORCESTER RD STE 100
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-5410
Practice Address - Country:US
Practice Address - Phone:908-670-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA1285451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty