Provider Demographics
NPI:1447093232
Name:POOTHAKARY, JERRYN
Entity type:Individual
Prefix:
First Name:JERRYN
Middle Name:
Last Name:POOTHAKARY
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 1:125 PARK DR APT 27
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5178
Mailing Address - Country:US
Mailing Address - Phone:708-890-0983
Mailing Address - Fax:
Practice Address - Street 1:125 PARK DR APT 27
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5178
Practice Address - Country:US
Practice Address - Phone:708-890-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.106926104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker