Provider Demographics
NPI:1447651906
Name:GRANT, JESSICA REGINA
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:REGINA
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 BOYLSTON ST.
Mailing Address - Street 2:APT # 3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-619-5937
Mailing Address - Fax:617-371-3038
Practice Address - Street 1:66 CANAL ST.
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-371-3040
Practice Address - Fax:617-371-3038
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)