Provider Demographics
NPI:1609292192
Name:BLAISDELL, JONATHAN (MA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:BLAISDELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ACCORD PARK DR STE A110
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1613
Mailing Address - Country:US
Mailing Address - Phone:781-435-7941
Mailing Address - Fax:
Practice Address - Street 1:40 ACCORD PARK DR STE A110
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1613
Practice Address - Country:US
Practice Address - Phone:781-435-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-09
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10709101Y00000X, 101YA0400X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional