Provider Demographics
NPI:1871057018
Name:LISTON, JENNA (BS, MED)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:LISTON
Suffix:
Gender:F
Credentials:BS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 EDITH AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3010
Mailing Address - Country:US
Mailing Address - Phone:617-818-2939
Mailing Address - Fax:
Practice Address - Street 1:111 MIDDLETON RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-4000
Practice Address - Country:US
Practice Address - Phone:978-777-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty